Behavioral Health
Call for Papers
Behavioral Health Care Through the Life Cycle:
Different Needs, Different Services
Chair: Constance Horgan, Brandeis University
Sunday, June 26 • 3:30 pm – 5:00 pm
●Physician Office Visits for Depression by Older
Americans: Who do They See and What Type of Care is
Provided?
Jeffrey Harman, Ph.D., Peter Veazie, Ph.D., Jeffrey Lyness,
M.D.
Presented By: Jeffrey Harman, Ph.D., Assistant Professor,
Health Services Research, Management and Policy, University
of Florida, PO Box 100195, Gainesville, FL 32611-0195; Tel:
(352) 273-6060; Fax: (352) 273-6075; Email: jharman@ufl.edu
Research Objective: Previous research has shown that
depression treatment for older persons primarily takes place
in the primary care sector, although it is not known whether
these visits are primarily to family practice physicians or to
internists and if the rate and type of treatment varied between
family practice and internal medicine physicians. The purpose
of this study is to assess patterns of depression treatment in
office-based settings by older patients.
Study Design: Data from the 2001-2002 National Ambulatory
Medical Care Survey, a nationally representative survey of
physician office visits in the United States conducted annually
by the National Center for Health Statistics (NCHS), are used.
The survey provides information on physician specialty,
diagnoses, medications prescribed, and other procedures and
therapies provided or ordered during each visit. Estimates of
rates of depression diagnosis, antidepressant prescribing, and
mental health counseling or psychotherapy were obtained for
all visits combined and by physician specialty. All estimates
were calculated using the weights provided by the NCHS to
obtain nationally representative estimates with 95%
confidence intervals that account for the complex sampling
design.
Population Studied: Physician office visits made by patients
aged 65 and over in 2000 and 2001 (N=14,372).
Principal Findings: A depression diagnosis was recorded
during 2.2% (CI: 1.7-2.6) of all office visits by older persons. A
depression diagnosis was recorded during 3.2% (CI: 1.9-4.5) of
visits to family/general practice physicians and during 2.5%
(CI: 1.8-3.3) of visits to internist. An antidepressant was
prescribed during 54.2% (CI: 43.6-64.8) of depression visits.
The rate of antidepressant prescribing during depression visits
did not significantly differ by physician specialty. For all
specialties, 92.8% of all antidepressants prescribed to treat
depression were SSRIs or “atypicals”. Mental health
counseling or psychotherapy was provided or recommended
during 42.1% (CI: 34.1-50.2) of visits with a depression
diagnosis. Counseling/psychotherapy was offered
significantly less frequently by internists (13.9% of visits, CI:028.7) than by all other specialties, including family/general
practice physicians (39.4%, CI: 26.9-51.9). Nearly two-thirds
of all depression visits made by elderly persons were to
primary care providers, with 32.4% of visits to family/general
practice physicians, 31.4% to internists, and only 25.7% of
visits to psychiatrists.
Conclusions: The majority of depression visits by older
persons continue to take place in the primary care sector, with
these visits equally distributed between family/general practice
and internal medicine physicians. There were no significant
differences in the rates of antidepressant prescribing between
the two type of primary care physicians, but family/general
practice physicians were more likely to provide counseling or
offer referral for psychotherapy than internists. Newer
generation antidepressants are now the primary form of
antidepressant treatment among this population.
Implications for Policy, Delivery, or Practice: Treatment of
late life depression continues to primarily take place in the
primary care sector, with antidepressant medication being the
modal form of treatment. It appears that family/general
practice physicians are more comfortable providing mental
health counseling or referring patients to psychotherapy than
internists.
Primary Funding Source: NIMH
●Does Motivation Influence Alcohol and Other Drug Use
(AOD) Treatment Outcomes for Adolescents?
Brooke Harrow, Ph.D., Kevin Smith, M.A., Ken Winters, Ph.D.,
Stephen Soldz, Ph.D., Annie Zhang, MPH, Kathleen Fleming,
M.ed
Presented By: Brooke Harrow, Ph.D., Assistant Professor,
College of Nursing and Health Sciences, University of
Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA
02125; Tel: (617)287 7579; Fax: (617) 287 7527; Email:
Brooke.Harrow@umb.edu
Research Objective: To examine and compare the roles of
intrinsic motivation for treatment, legal coercion and other
extrinsic pressures for treatment on client outcomes of AOD
use (including dependency and abuse), negative
consequences of AOD use, functioning, and school
attendance for adolescents receiving publicly funded AOD
treatment.
Study Design: Two hundred and forty four adolescents were
interviewed as they entered residential AOD treatment.
Analyses are based on a sample of 173 with completed 12month follow-up interviews and non-missing values for all the
variables included in the models. Administrative data from
Medicaid and the state treatment system were merged with
the client self-report data.
Intrinsic motivation was measured by a modification of the
motivation and readiness subscales of the Circumstances,
Motivation, Readiness and Suitability Scales (CMRS DeLeon,
1991;) from the baseline interview instrument. Exploratory
factor analyses of the CMRS items were conducted. The
results indicated that eight items taken from those CMRS
subscales could be combined to form an intrinsic motivation
measure with a coefficient alpha of .88. Three additional
items were taken from the CMRS and modified in order create
a scale assessing pressure to leave treatment.
The focus was on five post-treatment outcomes: two
measuring substance abuse severity, two measures of
psychological functioning, and attendance at school. All five
were measured at the 12 month follow-up interview. With the
exception of the dichotomous school attendance outcome,
relationships among the variables in our model were tested
using structural equation modeling (SEM). Logistic
regression was used for the analysis of the only binary
outcome, school attendance.
Population Studied: Massachusetts adolescents aged 12-19
years with public funding admitted to residential AOD
treatment programs.
Principal Findings: Males and respondents with higher Youth
Self Report (YSR) externalizing scores had higher Pressure to
Leave Treatment scores (extrinsic pressure). Pressure to
Leave Treatment, however, did not affect any of the treatment
services in the model. Motivation/Readiness scores (intrinsic
motivation) were not associated with any of the demographic
or baseline characteristics we collected. However,
respondents with higher Motivation/Readiness (M/R) scores
were more likely to have long residential stays and to join
support groups.
Four variables had significant direct effects on the number of
follow-up drug use days. The number of days was positively
associated with the number of baseline use days and YSR
externalizing scores, and negatively impacted by confinement
time and attendance at support groups. Tracing paths back
from the outcome, M/R had a small negative effect on drug
use days through its indirect effect on support group
participation (beta=.25*-.17=-.04). Pressure to Leave
Treatment was not related to subsequent drug use in this
sample.
Conclusions: Intrinsic motivation as measured by Motivation
and Readiness scores had a small negative effect on drug use
days through its indirect effect on support group participation.
Extrinsic motivation as measured by Pressure to Leave
Treatment was not related to subsequent drug use.
Implications for Policy, Delivery, or Practice: Previous
prediction studies with adults have demonstrated that
dynamic attributes, such as treatment motivation, have a
greater impact on retention than fixed background variables
(Condelli and DeLeon, 1993; DeLeon, 1991). However, this
association has not been investigated for adolescents. We
distinguished between intrinsic motivation (an individual’s
reason for change and perceived need for treatment) and
extrinsic motivation (external constraints outside the client’s
control), which we hypothesized would have different patterns
of effects.
Primary Funding Source: NIAAA
●Depression and At-Risk Alcohol Use Outcomes for Older
Primary Care Patients in Integrated Care and Enhanced
Specialty Referral
Dean Krahn, M.D., Steve Bartels, Ph.D., Eugenie Coakley,
MPH, Dave Oslin, Ph.D., Henry Chung, M.D., Sue Levkoff,
Sc.D.
Presented By: Dean Krahn, M.D., William S. Middleton
Memorial Veterans Hospital, 2504 Overlook Terrace,
Madison, WI 53705; Tel: (608) 280-7015; Email:
dean.krahn@med.va.gov
Research Objective: Although studies have shown that
integrated mental health care delivery in primary care results
in better outcomes for older patients than usual care, no
research has examined whether this collaborative model
results in better outcomes than enhanced referral to specialty
mental health clinics.
This paper compares clinical outcomes for older adults with
depression and at-risk drinking in integrated versus enhanced
referral care.
Study Design: Older adults aged 65 and above were screened
at primary care clinics from 10 study sites throughout the
U.S.A. Those who met diagnostic criteria for depression,
anxiety, and/or at-risk alcohol consumption were randomly
assigned to either IC or ES models.
Population Studied: Older adults (over 65 years old) users of
primary care services at eleven study sites throughout the
country. Study settings included community health centers,
VA facilities, and other community primary care clinics.
Over 25,000 older adults were screened for mental health and
alcohol drinking problems in primary care settings. more than
2,200 elderly primary care patients with depression, anxiety,
and at-risk drinking participated in this study.
Principal Findings: Overall depression remission rates and
symptom reduction were similar for both models at 6 month
follow-up. However, ESR was associated with a greater
reduction in depression severity compared to IC for major
depression (95% CI 1.0, 4.5, p=.003).
Six months outcomes demonstrate greater engagement in
care in the collaborative care model (p<0.001) and significant
time effects with reductions in both weekly drinking (p<0.001)
and binge drinking (p<0.001),
Conclusions: These findings suggest that outcomes for older
persons with minor depression are equivalent to outcomes in
referral. For major depression, outcomes may be superior in a
system in which referral is optimized. The study shows that a
significant number of older at-risk drinkers can substantially
modify their drinking over time, regardless of treatment
models.
Implications for Policy, Delivery, or Practice: The study
results support the New Freedom Commission's
recommendations to let patients choose the system that best
meets their needs.
Primary Funding Source: SAMHSA
●The Effectiveness of Substance Abuse Treatment
Programs on Adolescents with Learning Disabilities
Jennifer Yu, Sc.D., Stephen Buka, Sc.D., Marie McCormick,
M.D., Sc.D., Garrett Fitzmaurice, Sc.D.
Presented By: Jennifer Yu, Sc.D., Research Fellow, Institute
for Health Policy Studies, University of California, San
Francisco, 3333 California Street, Suite 265, San Francisco, CA
94143-0936; Tel: (415) 514-0244; Fax: (415) 476-0705; Email:
jyu1@itsa.ucsf.edu
Research Objective: Despite the high prevalence of learning
disabilities (LD) among substance abusing adolescents, no
prior studies have examined the effectiveness of substance
abuse programs on adolescents with LD. The objectives of
this paper were 1) to determine if chemically dependent
adolescents with comorbid LD derived less effective treatment
results than chemically dependent adolescents with no LD;
and 2) to examine whether various elements of the treatment
program influenced the relationship between LD and posttreatment outcomes.
Study Design: This secondary data analysis used an
observational study of adolescents in substance abuse
treatment facilities who were interviewed and tested at the
beginning of their treatment and then followed up six months
after the initial assessment. Participants were categorized as
having a learning disability based on the discrepancy between
their cognitive and academic test scores. Logistic regression
models were employed in which LD status predicted
substance use relapse, depression, arrests, and utilization of
further counseling and support services. Subsequent
regression analyses included prior admissions to treatment
programs, duration of treatment, and treatment completion
as interaction terms in order to determine if these elements of
the treatment program modified the association between LD
and the outcomes of interest.
Population Studied: The study sample was derived from the
Harvard Teen Drug Study, a cohort of adolescents aged 15-19
years who met full DSM criteria for chemical dependence.
Subjects were recruited between 1992-1993 from residential
treatment centers for substance abusing adolescents in
Massachusetts. Among the 201 adolescents followed up in
the study, 21% were identified as having LD.
Principal Findings: Compared to chemically dependent
teenagers with no LD, those classified with LD were twice as
likely to re-use substances at least once (OR=2.08, 95% CI:
1.02-4.27). Among a subgroup of adolescents experiencing
psychological problems, LD teens were significantly less likely
than teens without LD to exhibit help-seeking behavior after
receiving treatment (OR=0.11, 95% CI: 0.02-0.75). In addition,
the association between LD and regular Alcoholics
Anonymous/Narcotics Anonymous attendance was modified
by prior admissions to treatment programs (OR=8.60; 95%
CI: 1.64-44.61) as well as a longer treatment length (OR=4.51,
95% CI: 1.21-17.55). LD teenagers who completed the
treatment program also experienced a greater decrease in
current depression when compared to LD teenagers who did
not complete the treatment (OR=0.09, 95% CI: 0.01-0.97).
Conclusions: In general, teenagers with learning disabilities
were less likely to experience positive outcomes from a
substance abuse treatment program when compared to
teenagers with no LD. Furthermore, prior admissions to
treatment programs, longer treatment length, and treatment
completion had positive influences on some of the posttreatment outcomes for individuals with LD.
Implications for Policy, Delivery, or Practice: This research
is the first to examine the influence of LD on substance abuse
treatment and provides a foundation from which to consider
various substance abuse treatment policies and practices
geared towards individuals with LD. These implications
include screening for LD during initial intake into treatment
programs, modifying treatments to fit the specific cognitive
and learning needs of the treatment participant, and
increasing health insurance coverage to allow longer stays in
treatment facilities.
Primary Funding Source: NIDA
●The Impact of Childhood Learning Disabilities on Adult
Functioning and the Influence of Elementary Special
Education Services
Jennifer Yu, Sc.D., Stephen Buka, Sc.D., Marie McCormick,
M.D., Sc.D., Garrett Fitzmaurice, Sc.D.
Presented By: Jennifer Yu, Sc.D., Research Fellow, Institute
for Health Policy Studies, University of California, San
Francisco, 3333 California Street, Suite. 265, San Francisco, CA
94143-0936; Tel: (415) 514-0244; Fax: (415) 476-0705; Email:
jyu1@itsa.ucsf.edu
Research Objective: Although a great deal of research has
been devoted to the cognitive, academic, and socioemotional
characteristics of children with learning disabilities (LD) and
the impact of special education on LD, far less is known about
the long-term prognoses of LD children as they reach
adulthood. This paper addresses this issue by: 1) examining
the association between verbal learning disabilities (VLD) and
nonverbal learning disabilities (NVLD) and their relationship
with adult functioning in the domains of educational
attainment, employment and occupational status, social
relationships, suicidality, and arrests; and 2) determining
whether receipt of special education services in elementary
school influences the relationship between subtypes of LD and
outcomes of adult functioning.
Study Design: Individuals were identified as VLD or NVLD at
age seven based on their discrepancy between cognitive
performance and academic achievement in reading, spelling
and arithmetic. Logistic regression models were employed in
which learning disability status at age 7 predicted adult
functioning outcomes. Subsequent regression analyses
included receipt of elementary special education to determine
if these services modified the association between LD
subtypes and adult functioning.
Population Studied: These analyses utilized a sample of 575
individuals studied prospectively since birth as part of the
Providence, Rhode Island cohort of the National Collaborative
Perinatal Project, an observational study initiated in the early
1960’s with follow-up conducted in 1996 between the ages of
30 and 39 (mean=33.6). 35% of subjects were classified as
VLD and 21% were classified as NVLD.
Principal Findings: Compared to adults with no LD, VLD
adults were nearly twice as likely to drop out of high school
(OR=1.93), and NVLD adults were twice as likely to report
having no close social relationships (OR=2.54). Other
outcomes of adult functioning were not significantly
associated with either VLD or NVLD. Receipt of special
education services in elementary school was found to modify
the relationship between VLD and current unemployment
(OR=3.69), and VLD in suicide attempts (OR=5.28). No
significant effect modification was found for a corresponding
relationship with NVLD.
Conclusions: These findings suggest that individuals
identified with childhood LD generally do not have an
increased risk of negative outcomes in adult functioning when
compared to individuals with no disabilities, with the
exception of increased rates of dropout among VLD adults
and a lack of close friendships among NVLD individuals.
However, receipt of elementary special education did increase
the risk of poor adult functioning among individuals with VLD.
Implications for Policy, Delivery, or Practice: A number of
children’s health and education policy implications can be
derived from this study. Suggestions include revising special
education policies to reduce the negative impact of labeling on
special education students. In addition, these findings
provide historical lessons regarding the ramifications of a
poor educational and social environment such as those
experienced by pre-1970’s special education students that can
elucidate further ways to increase the benefits of the current
special education system to students with LD.
Primary Funding Source: Maternal and Child Health Bureau
Call for Papers
Innovative Behavioral Health Care Studies
Leading the Field
Chair: Margarita Alegria, Cambridge Health Alliance and
Harvard Medical School
Sunday, June 26 • 5:30 pm – 7:00 pm
●Adverse Events During Medical and Surgical
Hospitalizations for Persons with Schizophrenia
Gail Daumit, M.D., MHS, Donald M. Steinwachs, Ph.D., Peter
J. Pronovost, M.D., Ph.D., Christopher B. Anthony, Eliseo
Guallar, M.D., DrPh, Daniel E. Ford, M.D., MPH
Presented By: Gail Daumit, M.D., MHS, Assistant Professor,
Medicine, Johns Hopkins University, 2024 East Monument
Street, Suite 2-500, Baltimore, MD 21205; Tel: (410) 614 6460;
Fax: (410) 614 0588; Email: gdaumit@jhmi.edu
Research Objective: Persons with schizophrenia comprise a
vulnerable population with a mortality rate 2.5 times higher
than the general population. Despite this, little is known about
patient safety for persons with schizophrenia, and they may be
at high risk for adverse events. Virtually all inpatient deaths in
schizophrenia occur during admissions to medical or surgical
(not psychiatric) services, where provider inexperience such as
misinterpretation of somatic symptoms or antipsychotic drug
errors could contribute to adverse events. We aimed 1) to
estimate the prevalence of adverse events in medical and
surgical hospitalizations for persons with schizophrenia
compared to those without schizophrenia and 2) to examine
the relation between adverse events and ICU admission, inhospital death and increased length of stay (LOS) for persons
with schizophrenia.
Study Design: We performed a cross-sectional study using
administrative data on Maryland acute care hospital
discharges.
Population Studied: We studied all acute care
hospitalizations in Maryland in 2001-2002 on medical and
surgical services and compared hospitalizations with a
secondary diagnosis of schizophrenia to those without
schizohprenia. For primary outcomes, we applied AHRQ's
Patient Safety Indicators (PSIs), developed to detect adverse
events in administrative data. The PSIs are validated and each
has explicit inclusion/exclusion criteria. We studied PSIs with
an adequate number of events for analysis. We compared PSIs
for hospitalizations with a secondary diagnosis of
schizophrenia to those without and performed multivariate
logistic regression to determine the association between
schizophrenia and each PSI adjusting for patient (age, race,
gender, insurance, medical comorbidity) and hospital
(teaching/trauma center) characteristics. For hospitalizations
with schizophrenia, we examined similarly the association
between each PSI and the risk for ICU admission and inhospital death (not 'Failure to rescue' where death is an
inclusion criteria), and we used median regression to examine
the relation of each PSI to increased LOS.
Principal Findings: There were 1746 medical/surgical
hospitalizations with a secondary diagnosis of schizophrenia
and 732,210 without schizophrenia. The mean age was similar
at 55 years. Hospitalizations with schizophrenia had a higher
prevalence of: non-whites (50% vs. 34%); men (48% vs. 38%)
and public insurance (75% vs. 50%) than those without. Most
medical comorbidities were more common for schizophrenia.
Hospitalizations with schizophrenia had the following
adjusted relative odds (OR, 95%CI) of having a PSI compared
to those without schizophrenia: Infections due to medical
care, OR 2.5(1.3-4.9); post-op respiratory failure, OR 2.1(1.43.1); post-op DVT, OR 2.0(1.2-3.3); post-op sepsis OR 2.3(1.53.5). For hospitalizations with schizophrenia, having these
PSIs showed a higher adjusted OR,(95%CI) for ICU
admission: resp. failure, OR=13,(12-14); DVT, OR=4,(3-4);
sepsis, OR=7,(2-33). The adjusted ORs for death were higher
with PSIs of resp. failure, OR=9,(3-26) and sepsis, OR=7,(232). The median adjusted increase in LOS in days (95%CI) for
schizophrenia was elevated significantly for: infections,18,(1520); resp. failure, 14,(10-18); DVT,10,(7-14); sepsis, 24(21-27).
Conclusions: Medical and surgical hospitalizations for
persons with schizophrenia had at least twice the odds of
several types of adverse events than those without
schizophrenia. Adverse events were associated with increases
in ICU admission, length of stay and in-hospital death.
Implications for Policy, Delivery, or Practice:
Understanding factors contributing to adverse events will be
important to improving safety and potentially decreasing
premature mortality in this vulnerable population.
Primary Funding Source: NIMH
●Reliability and Validity of the BASIS-R Mental Health
Survey for Euro-Americans, African-Americans and Latinos
Susan Eisen, Ph.D., Mariana Gerena, MA, Gayatri
Ranganathan, MS
Presented By: Susan Eisen, Ph.D., Associate Professor,
Health Research Scientist, Center for Health Quality,
Outcomes & Economics Research, Edith Nourse Rogers
Memorial Veterans Hospital, 200 Springs Road (152),
Bedford, MA 01730; Tel: (781)687-2858; Fax: (781)687-3106;
Email: seisen@bu.edu
Research Objective: The purpose of this study was to
evaluate factor structure, reliability, validity and sensitivity to
change of the revised Behavior and Symptom Identification
Scale (BASIS-R), for the three largest race/ethnicity groups in
the US: Euro-Americans (white), African-Americans (black)
and Latinos. BASIS-R is a self-report mental health
instrument assessing six symptom/functioning domains.
Self-report measures are widely recognized as important
indicators of treatment effectiveness. However, many widely
used measures have not been validated in diverse
racial/ethnic groups. Because expression of psychiatric
symptoms may vary across racial/ethnic groups, the use of
inappropriate outcome measures may under-or over-estimate
prevalence and/or treatment effects for psychiatric disorders.
Consequently, it is important to test and validate assessment
instruments among diverse groups.
Study Design: The BASIS-R instrument and demographic
information (including race/ethnicity) was obtained from
psychiatric inpatients at admission and before discharge, and
from outpatients at intake and 30-60 days later. We examined
rates of missing data, confirmatory factor analysis, internal
consistency reliability, validity and sensitivity to change within
each race/ethnicity group.
Population Studied: The population included 5,806
individuals receiving inpatient (n=2,620) or outpatient
(n=3,186) mental health and/or substance abuse services at
one of 28 programs throughout the U.S. 69% were white,
17% were African-American and 6% were Latino. Other race
groups are excluded due to insufficient sample size.
Principal Findings: Missing data rates ranged from <1% to
3.8% with virtually no variation among race/ethnicity groups.
Confirmatory factor analysis yielded statistically significant chisquares for each race/ethnicity group. However, because the
chi-square test of fit is affected by large sample sizes,
additional fit statistics were examined. The Adjusted
Goodness of Fit Index (AGFI), ranged from .84 to .89, the root
mean square error of approximation (RMSEA) was less than
.07, and incremental fit indices were .89 or higher for each
race/ethnicity group, indicating adequate fit. Internal
consistency reliability coefficients exceeded .70 for all six
symptom/functioning domains and for all three race/ethnicity
groups with one exception: for Latino inpatients, alpha was
.66 for the emotional lability domain. Correlations between
BASIS-R summary scores with SF-12 Mental Component
Scores were uniformly higher (r’s ranged from .68-.80) than
with SF-12 Physical Component Score (r’s ranged from .06.45) for each race/ethnicity group, supporting construct
validity of the instrument. In addition, specific
symptom/functioning scores differentiated among
corresponding diagnostic groups, supporting discriminant
validity. Among Euro-Americans, inpatients reported
significantly higher levels of symptoms and problems than
outpatients in all domains. However, among AfricanAmericans and Latinos, inpatient-outpatient differences were
significant in some, but not all domains. Analysis of change
over time showed statistically significant improvement among
inpatients for all race/ethnicity groups and among outpatients
for Euro-Americans in all domains; for African-American and
Latino outpatients, change was statistically significant in four
of six domains.
Conclusions: Most tests of reliability, validity and sensitivity
to change showed comparable results across three major
race/ethnicity groups.
Implications for Policy, Delivery, or Practice: BASIS-R
appears to be a promising instrument for routine assessment
of mental health status and outcome for Euro-Americans,
African-Americans and Latinos. Testing in other race/ethnicity
groups is needed to determine its generalizability to other
groups.
Primary Funding Source: NIMH
●Using Consumer Reports and Ratings to Compare
Managed Behavioral Health Plans
Laura Eselius, Ph.D., MPH
Presented By: Laura Eselius, Ph.D., MPH, Post-Doctoral
Research Associate, Taubman Center for Public Policy, Brown
University, Box 1977, Providence, RI 02912-1977; Tel: (401)8639311; Email: Laura_Eselius@brown.edu
Research Objective: To facilitate the use of consumer reports
and ratings to compare managed behavioral health plans, this
research sought to (1) identify reliable summary measures for
the Experience of Care and Health Outcomes (ECHO) survey,
a CAHPS instrument designed for behavioral health care
consumers, (2) develop a casemix adjustment model unique
to behavioral health care consumers, and (3) estimate the
extent to which subgroup differences reflect quality differences
rather than general reporting biases.
Study Design: Analyses were conducted using ECHO survey
data collected by 21 managed behavioral health plans between
September 2000 and February 2002. Factor analyses were
performed to identify composite reporting measures.
Multivariate regression analyses were used to develop and
evaluate alternative casemix adjustment models. Plan-byadjuster interaction terms were tested in the models to
determine whether adjuster coefficients differed across plans.
Population Studied: The sample included 3,067 individuals
enrolled in 12 commercial plans, and 1,001 individuals
enrolled in 9 Medicaid plans, for a total of 4,068 individuals
enrolled in 21 managed behavioral health plans. All
respondents had received behavioral health services from a
specialty provider within the previous year.
Principal Findings: Four composite measures adequately
summarized consumers’ reports about 22 care- and planrelated experiences. Similar factor structures appeared for
commercial and Medicaid respondents. Compared to the
factor-based measures, four composites defined a priori by
combining conceptually related items with the same response
scale exhibited better or similar internal consistency and planlevel reliability. Mental health status, general health status,
alcohol/drug use, age, education, and race/ethnicity emerged
as important adjusters. Additionally, income was important in
the commercial sample, and gender was important in the
Medicaid sample. The impact of adjustment on plan scores
was modest, but substantial enough to change plan rankings.
Plan-by-health-status interactions were statistically significant,
indicating that differences between consumers in better and
worse health were greater in some plans than others.
Conclusions: Four composites reflecting reports about timely
access to behavioral health care, patient-provider interaction,
treatment information, and plan approval and service, along
with global ratings of behavioral health care and health plan,
are recommended for reporting ECHO survey results.
Adjusting plan scores for casemix differences, including
differences related to mental health status and alcohol/drug
use, improves the fairness of plan comparisons. Subgroups
defined by health status differed more widely in their reports
and ratings in some plans than in others, suggesting the
presence of quality differences rather than general reporting
biases associated with health status.
Implications for Policy, Delivery, or Practice: With reliable
summary measures and appropriate casemix adjustment,
consumer reports and ratings can be useful for assessing and
comparing managed behavioral health plan performance.
Testing whether the effects of casemix adjusters are
homogenous across plans is a critical step in interpreting
subgroup and plan differences, a step that should be
incorporated into the analysis and reporting
recommendations for the ECHO and similar surveys.
Primary Funding Source: AHRQ, Alfred P. Sloan Foundation
and Harvard's Health Policy PhD Program
●Telemedicine Intervention to Improve Depression Care
in Rural CBOCs
John Fortney, Ph.D., Jeff M. Pyne, M.D., Mark J. Edlund, M.D.,
Dean E. Robinson, M.D., Dinesh Mittal, M.D., Kathy L.
Henderson, M.D.
Presented By: John Fortney, Ph.D., Associate Professor,
Center for Mental Healthcare and Outcomes Research, VA
HSR&D, 2200 Fort Roots Drive, North Little Rock, AR 72114;
Tel: (501)257-1726; Fax: (501)257-1749; Email:
john.fortney@med.va.gov
Research Objective: Intervention studies have demonstrated
the effectiveness of collaborative care models designed to
improve depression outcomes in primary care settings.
Interventions designed for and tested in large urban clinics are
not always applicable in small rural practices. Implementing
collaborative care for depression in small rural primary care
practices presents unique challenges because it is typically not
feasible to employ mental health specialists on site. The
purpose of the Telemedicine Enhanced Antidepressant
Management (TEAM) study was to adapt the depression
collaborative care model for small rural primary care practices
using telemedicine technologies (e.g., telephone, interactive
video, electronic medical records, and internet). The TEAM
intervention is designed to be implemented by offsite
personnel including nurse depression managers, clinical
pharmacists and consult psychiatrists. Telemedicine
facilitates communication between this centrally located
depression care team and providers practicing in
geographically diverse clinic locations. Offsite TEAM
personnel provide support for primary care physicians to
practice evidence-based medicine and to help patients sustain
treatment adherence. This telemedicine-based collaborative
care model has seven main components: 1) provider
education, 2) screening, 3) patient education/activation, 4)
outcomes monitoring and feedback, 5) medication
management, 6) psychiatric consultation, and 7) treatment
recommendations.
Study Design: This is an experimental effectiveness study
with primary data collection. The effectiveness of the
intervention was tested using an intent-to-treat perspective
with patients defined as the unit of analysis.
Population Studied: The study was conducted in seven small
rural Community Based Outpatient Clinics operated or
contracted by the VA. To be included in the study, CBOCs
must have: 1) treated 1,000 – 5,000 patients, 2) no on-site
psychiatrists, and 3) interactive video equipment available for
mental health. The study attempted to screen all CBOC
patients and enroll those patients with depression who could
be appropriately treated in primary care. Of the 24,882 CBOC
patients, 73.6% (n=18,306) were successfully screened prior to
their appointment and 6.9% screened positive (PHQ9 score
=12). Of those eligible, 91.3% agreed to participate in the
study and 91.9% of those attended their appointment and
were consented. Over an 18 month period, 395 patients were
enrolled.
Principal Findings: Six month follow-ups have been
completed for 348 subjects. The sample comprised mostly
elderly (mean age of 59) Caucasian (75%) males (92%) who
had on average 5.5 chronic physical health illnesses. Subjects
had moderate depression severity (PHQ=16.4), 2.7 prior
depression episodes, and 67% had prior depression
treatment. Controlling for casemix, results indicate that
intervention patients were more likely to experience a >50%
improvement in their depressive symptoms according to the
Hopkins Symptom Checklist (OR=1.9, p=0.03) and PHQ9
(OR=1.8, p=0.04). Likewise, intervention patients had
significantly greater (ß=0.05, p<0.001) health related quality of
life, as measured by the Quality of Well Being scale.
Intervention patients had much higher satisfaction across a
range of dimensions included in the Experience of Care and
Health Outcomes (ECHO) Survey.
Conclusions: Collaborative care models can be successfully
adapted for small rural primary care clinics using telemedicine
technologies.
Implications for Policy, Delivery, or Practice: VA is planning
for widespread implementation of collaborative care.
Telemedicine-based collaborative care is an evidence-based
treatment that should be considered for implementation in
small rural clinics.
Primary Funding Source: VA
●Influence of Patients' Requests for Directly Advertised
Prescription Drugs on Physicians' Treatment of
Depression: A Randomized Controlled Trial
Richard Kravitz, M.D., MSPH, Ronald Epstein, M.D., Mitchell
D. Feldman, M.D., MPhil, Carol E. Franz, PhD, Ladson
Hinton, M.D., Peter Franks, M.D.
Presented By: Richard Kravitz, M.D., MSPH, Professor &
Director, UCD Center for HSR/PC, 2103 Stockton Boulevard,
Grange Building, Suite 2400, Sacramento, CA 95817; Tel:
(916)734-1248; Email: rlkravitz@ucdavis.edu
Research Objective: Direct-to-consumer (DTC) advertising of
prescription drugs in the United States is both ubiquitous and
controversial. The objective of this research was to ascertain
the effects of patients’ DTC-related requests on physicians’
initial treatment decisions (prescribing, referral, and follow-up)
in patients with depressive symptoms.
Study Design: The study was conducted as a randomized trial
using Standardized Patients (SPs). Six SP roles were created
by crossing 2 conditions (major depression or adjustment
disorder) with 3 medication request types (brand-specific,
general, or none). SPs (each trained to portray 1 role) were
randomly assigned to make 2 unannounced visits per
physician (with randomization constrained so that physicians
saw 1 SP portraying major depression and 1 portraying
adjustment disorder).
Population Studied: The 152 participating physicians were
recruited from diverse practices (solo, group, and HMO) in 3
U.S. cities (Sacramento, CA; San Francisco, CA; Rochester,
NY). SPs were all white middle aged women with previous
acting experience.
Principal Findings: In major depression, rates of
antidepressant prescribing were 53%, 76%, and 31% for SPs
making brand-specific requests, general requests, and no
requests, respectively (p<.0001). In adjustment disorder,
antidepressant prescribing was 55%, 39%, and 10%,
respectively (p<.0001). The results were confirmed in
generalized linear mixed models that accounted for clustering
and adjusted for site, physician, and visit characteristics..
“Minimally acceptable initial care” (any combination of an
antidepressant, mental health referral, or follow-up within two
weeks) in the major depression role was offered to 98% of SPs
making a general request, 90% of those making a brandspecific request, and 56% of those making no request
(p<0.001).
Conclusions: Patients’ requests have a profound effect on
physician prescribing in major depression and adjustment
disorder. DTC advertising may have competing effects on
quality, potentially both averting under-use and promoting
over-use.
Implications for Policy, Delivery, or Practice: The results of
this trial sound a cautionary note for DTC advertising but also
highlight opportunities for improving care of depression (and
perhaps other chronic conditions) by using public media
channels (including thoughtfully regulated commercial
advertising) to expand patient involvement in care. From a
legal perspective, these data pose a possible challenge to the
“learned intermediary rule.” Further research in other clinical
contexts is needed to confirm the results of this study and
determine the relative effects of DTC advertising and noncommercial media on patient activation and outcomes.
Primary Funding Source: NIMH
Call for Papers
Addressing Challenges in Behavioral Health Care through
Benefit Design & Management Mechanisms
Chair: Thomas Croghan, RAND
Tuesday, June 28 • 8:30 am – 10:00 am
●Impact of an Antidepressant Adherence Improvement
Program in a Managed Care Organization
Kara Bambauer, Ph.D., Stephen B. Soumerai, Sc.D., Alyce S.
Adams, Ph.D., Fang Zhang, MS, Rick Weisblatt, Ph.D., Neil
Minkoff, M.D., Andrea Grande, RPh, Dennis Ross-Degnan,
Sc.D.
Presented By: Kara Bambauer, Ph.D., 133 Brookline Avenue,
6th floor, Boston, MA 02215; Tel: (617)509-9849; Email:
kzbambauer@post.harvard.edu
Research Objective: Depression is a major contributor to
morbidity and mortality, yet adherence to effective
antidepressant treatment remains low. Health Employer
Information Data Set (HEDIS) antidepressant (AD)
management scores are an important basis for measuring
quality of depression care by managed care organizations
(MCOs) in the United States. Harvard Pilgrim Health Care, a
managed care insurance plan in New England, sought to
improve its quality of depression care by implementing faxed
alerts to physicians when their patients had a gap of ten or
more days between AD refills. HPHC predicted that this
reminder system would improve physician-patient
communication about medication management and improve
antidepressant adherence rates.
Study Design: The Antidepressant Compliance Program
(ACP) began in May 2003. We used interrupted time-series
analyses to examine the rates and timing of AD refills for one
year before and one year after the ACP began (May 2002-May
2004).
Population Studied: Patients were included if they had an
episode of AD treatment preceded by at least 100 days
without AD use. Only the first such episode was included for
each patient. During the ACP, physicians of patients who had
gaps of more than ten days without a refill after their AD
prescription ran out received a faxed alert. Patients whose
gaps in therapy continued for >30 days were considered AD
adherence failures. We used segmented regression models to
evaluate whether the ACP had a significant impact on the
trend in the proportion of patients who became AD adherence
failures among patients with >10 days gaps in AD therapy.
Principal Findings: Among 34,523 patients included in this
study, 20,697 experienced gaps in AD therapy >10 days
(60%). Among patients with gaps, 14,423 (70%) proceeded
to become AD adherence failures. Rates of patients with gaps
>10 days and rates of AD adherence failure decreased
significantly following the ACP. Controlling for a slightly
declining baseline trend, the rate of AD adherence failure
among those with gaps >10 days declined from 78% (95%
C.I.:74%,82%) at month 6 prior to the fax program to 62%
(95% C.I.:58%,66%) and 54% (95% C.I.:49%,58%) at six and
12 months post policy respectively. The rate at month 12
represented a 22% decrease (95% C.I.:17%,26%) in the rate of
AD adherence failures compared to baseline.
Conclusions: We found that faxed reminders to prescribing
physicians were associated with a significant decline in the
rate of AD adherence failure. The declining rate of failure
among patients who experience gaps of more than 10 days
indicates that physicians who receive a fax warning of
impending problems in adherence may become more vigilant
about preventing these gaps to progress to treatment failure.
Implications for Policy, Delivery, or Practice: Managed care
organizations should consider using this form of faxed
reminder system for physicians to improve rates of treatment
adherence for other diseases.
Primary Funding Source: Harvard Pilgrim Healthcare
Foundation
●Demonstration of a Process-Outcome Link for Smoking
Cessation
Melissa Farmer, Ph.D., Elizabeth M. Yano, Ph.D., Brian S.
Mittman, Ph.D., Scott E. Sherman, M.D., MPH
Presented By: Melissa Farmer, Ph.D., Researcher, Center for
the Study of Healthcare Provider Behavior, VA, 16111 Plummer
Street (152), Sepulveda, CA 91343; Tel: (818) 891-7711 ext 5475;
Fax: (818) 895-5838; Email: Melissa.Farmer@med.va.gov
Research Objective: Despite the availability of effective
smoking cessation treatments, veterans’ smoking rates
remain 43% higher than the national population. VA
performance measures have demonstrated significant gains in
tobacco use screening and counseling, but the degree to
which this translates into actual changes in patient behavior is
unknown. We examined the relationship between discrete
site-level process-of-care measures (e.g., counseling) and
clinical outcomes for smoking cessation (30-day abstinence)
in a representative sample of VA primary care patients.
Study Design: Using data from the Quality Improvement Trial
for Smoking Cessation (QUITS), an organizational
intervention trial to implement smoking cessation guidelines
at 18 VA facilitates, we fit a cluster-adjusted logistic model
examining process-quality measures as predictors of
successful smoking cessation. Site-level process data came
from a survey of site administrators to assess the process of
care for smoking cessation including measures of tobacco use
screening, proportion of smokers counseled, proportion
referred to a smoking cessation clinic or program, site selfmonitoring of screening and counseling performance, and
having a follow-up system. Outcome measures from 12- and
18-month patient surveys included 30-day abstinence,
controlling for variations in patient-level demographics, health
and smoking status (baseline quit attempt, stage of change).
Population Studied: Site-level data came from 18
Southwestern VA facilities including New Mexico, Arizona,
Nevada, western Texas and California. Outcome patient-level
data came from a sample of veterans who were current
smokers and VA primary care patients with three or more VA
visits in the prior year surveyed at baseline (n=1941), 12 month
follow-up (n=1038) and 18 month follow-up (n=885).
Principal Findings: At 12-months follow-up, patients had an
increased odds of being abstinent at sites that at baseline,
reported more frequent screening for tobacco use
(OR=2.10;95%; CI:1.15-3.83) counseling (OR=1.61; CI:1.01-2.57)
and referral (OR=1.28; CI:1.03-1.59). By 18-months, the odds
of abstinence were further increased at sites that reported
more frequent screening (OR=1.88; CI:1.02-3.46) and
counseling (OR=1.58; CI:1.06-2.35). Site-performance
monitoring for tobacco use screening also was associated
with higher odds of abstinence at 12-months (OR=2.38;
CI:1.43-3.95) and 18-months (OR=2.03: CI:1.35-3.03). Patients
at sites that established counseling follow-up systems had
increased odds of quit attempts (1.25; CI:1.05-1.50) but no
significant difference in odds for abstinence.
Conclusions: Site-level process-of-care measures predict
clinical outcomes for smoking cessation. Patients at primary
care sites that at baseline reported more frequent tobacco use
screening, counseling, referral, and performance monitoring
had increased odds of abstinence 12 and 18 months later.
Implications for Policy, Delivery, or Practice: This study
demonstrates a process-outcome link between smoking
cessation performance measures and veterans’ actual quit
attempts and cessation, supporting VA’s process
measurement as a valid marker for ultimately helping veterans
quit smoking.
Primary Funding Source: VA
●Health Plan Performance on Antidepressant Medication
Management: Relationship with Organizational
Characteristics
Constance Horgan, Sc.D., Elizabeth Levy Merrick, Ph.D.,
MSW, Sarah Hudson Scholle, Dr. P.H., Sarah Shih, MPH
Presented By: Constance Horgan, Sc.D., Professor and
Director, Center for Behavioral Health, Schneider Institute for
Health Policy, Brandeis University, 415South Street - Maildrop
035, Waltham, MA 02454-9110; Tel: (781) 736-3916; Fax: (781)
736-3905; Email: horgan@brandeis.edu
Research Objective: Improving the treatment of depression
in primary care is an important goal given the low rates of
appropriate treatment for a disorder that is highly prevalent
and treatable. Evidence for needed improvement comes from
relatively low and stagnating results on health plan
performance measures for antidepressant medication
management (AMM) from the National Committee for
Quality Assurance's (NCQA's) Health Plan Employer Data
and Information Set (HEDIS). Within these problematic
overall results, however, some health plans perform much
better than others and improve over time. This study
examines whether performance and improvement over time
on HEDIS measures differ by how health plans organize,
finance and administer behavioral health care.
Study Design: We link NCQA health plan information (HEDIS
AMM and CAHPS patient satisfaction data) with data from a
nationally representative survey of health plans' commercial
managed care products for 1999 and 2003 to identify
characteristics related to AMM performance. The survey
included 434 health plans in 1999 (response rate = 92%) and
368 health plans in 2003 (response rate = 83%). Health plan
participants in HEDIS totaled 385 for 1999 and 300 for 2003.
We include all health plans present in both data sets. We
examine selected health plan characteristics in organization,
provider, and consumer domains and test their association
with AMM measures using bivariate and multivariate
methods.
Population Studied: Commercial health plans with managed
care products.
Principal Findings: For all HEDIS participants, mean
performance on AMM measures ranged from 21% to 59% in
1999 with virtually no change in 2003 (20% to 61%), while
many other measures were higher and/or showed
improvement. For example, use of beta-blockers after heart
attack treatment reached 94% in 2003. There is wide variation
in examined health plan characteristics. The percent of
managed care products that contracted with a specialty
behavioral health care organization rose from 58% in 1999 to
71% in 2003. We report on the relationship between marker
variables from each domain: Contracting arrangement (with
specialty behavioral healthcare vendor, comprehensive
network, or internal provision), feedback to primary care
physicians on adherence to depression guidelines, and cost
sharing level for SSRIs.
Conclusions: The linkage of depression treatment
performance measures with a range of health plan
characteristics can provide insight into organizational features
that may facilitate better performance and improvement over
time. It is important to examine health plan features within
several key domains.
Implications for Policy, Delivery, or Practice: Study results
will contribute to understanding the connection between
performance on HEDIS AMM measures and selected health
plan characteristics in the organization, provider and
consumer domains. The marker approach provides a basis for
exploring which types of health plan factors should be pursued
in greater depth as a way to improve medication management
of depression. This will help to improve the clinical quality of
depression care through economic and systems approaches
by pointing the way towards actionable health plan factors that
influence performance on quality indicators.
Primary Funding Source: RWJF
●Changes in Antipsychotic Pharmacotherapy and
Healthcare Costs Following a New Diagnosis of Diabetes
among Patients with Schizophrenia
Douglas Leslie, Ph.D., Robert Rosenheck, M.D.
Presented By: Douglas Leslie, Ph.D., Assistant Professor,
Psychiatry/Epidemiology and Public Health, Yale School of
Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT
06516; Tel: (203) 932-5711 x4015; Fax: (203) 937-3433; Email:
douglas.leslie@yale.edu
Research Objective: Previous research has documented the
increased risk of diabetes mellitus (DM) associated with
atypical antipsychotic medications. However, little is known
about how clinicians respond to new-onset diabetes in
patients with schizophrenia who are treated with these drugs,
or the costs associated with managing diabetes in this
population. The objective of this study is to investigate how
antipsychotic pharmacotherapy and healthcare costs change
following a new diagnosis of diabetes mellitus (DM) among
patients with schizophrenia.
Study Design: Patients with no history of DM who had at
least 2 outpatient visits in a specialty mental health clinic with
a primary or secondary diagnosis of schizophrenia, and who
were prescribed a consistent regimen of antipsychotic
monotherapy during any 3-month period between June 1999
and September 2000, were followed through September 2001
using administrative data from the Department of Veteran
Affairs (VA). Patients newly diagnosed with DM were
identified, along with a matched comparison group of patients
who were not subsequently diagnosed with DM. Medication
changes and costs were compared across the DM and nonDM groups, and between patients on atypical and
conventional antipsychotics. The additional cost associated
with DM treatment attributable to each atypical antipsychotic
medication was calculated.
Population Studied: VA outpatients diagnosed with
schizophrenia.
Principal Findings: Of 56,849 patients with schizophrenia
who were stable on an antipsychotic medication and had
complete demographic data, 4,132 (7.0%) were subsequently
diagnosed with diabetes (7.4% of patients on atypicals and
7.1% on conventionals). Differences in the proportions of
diabetic and matched non-diabetic patients who switched or
discontinued antipsychotic drugs were small, and there were
few differences between those on atypicals versus
conventionals. The average marginal cost of treating a patient
with diabetes was $3,104 over an average of 15.7 months
($6.59 per day) follow-up. Since the attributable risks of
diabetes with atypicals averaged 0.875%, the average
additional daily cost per patient attributable to each atypical
medication was small, ranging from $0.003 for risperidone to
$0.134 for clozapine.
Conclusions: Surprisingly, a new diagnosis of diabetes did
not result in substantial antipsychotic medication changes,
even among patients on clozapine or olanzapine. Although
costs of treating patients with newly diagnosed diabetes were
substantial, the increased costs attributable to atypicals were
small compared to the costs of the medications themselves
and other substantial health costs in this population.
Implications for Policy, Delivery, or Practice: DM risk is not
likely to affect the overall cost-effectiveness of atypical
antipsychotic medications. Nevertheless, it is important that
patients with schizophrenia be monitored for excessive weight
gain and increased DM risk. For patients at increased risk for
DM, clinicians should consider prescribing antipsychotic
medications associated with lower risk of DM, such as
risperidone or conventional antipsychotics.
Primary Funding Source: VA
●Expanded Mental Health Benefits and Outpatient
Treatment Intensity
Anthony Lo Sasso, Ph.D., Richard C. Lindrooth, Ph.D., Ithai Z.
Lurie, MA, John S. Lyons, Ph.D.
Presented By: Anthony Lo Sasso, Ph.D., Associate Professor,
Division of Health Policy and Administration, School of Public
Health, University of Illinois, Chicago, 1603 West Taylor,
Chicago, IL 60612; Tel: (312)413-1312; Fax: (312)996-5653;
Email: losasso@uic.edu
Research Objective: Both the United States Surgeon
General’s Report and the President’s New Freedom
Commission recommend that improving access to behavioral
health care should be an important national priority.
Behavioral healthcare is different than many other forms of
healthcare as nearly all theories of treatment and every existing
evidence-based practice assumes multiple sessions as an
expectation of receiving treatment. Therefore, initiation of
services is only one indicator of access to treatment. Whether
or not a recipient who begins services actually engages in
treatment is a second level indicator of access. Our goal is to
measure the mental health outpatient treatment intensity
effects of an expansion of mental health benefits for
employees of a large US-based company.
Study Design: Claims and enrollment data files were acquired
from the intervention company through their claims data
manager. For use as a comparison group, we also acquired
claims data on a random sample of employed persons from
Medstat’s Marketscan database during the same time period
as the intervention data set. Our analytical approach is to
compare the change over time in the intervention group
before and after the benefit change to the change over time in
the comparison group. Our outcome variables are mental
health treatment initiation; the number of outpatient visits
within in an episode of treatment; and a binary variable
representing whether the episode had eight or more
outpatient treatment visits, an indicator for whether the
person receives a sufficient "dose" of treatment.
Population Studied: The employees of a large Fortune 50
manufacturing firm with locations throughout the US and a
comparison group comprised of a random sample of workers
from other large self-insured employers over the years 19951998.
Principal Findings: Our empirical results suggest that the
combination of benefit changes instituted by the company
was successful in not only encouraging more employees to
enter treatment, but also in enabling more patients to stay in
treatment longer, increasing the likelihood that they receive
the appropriate minimum "dose" of eight outpatient therapy
visits. Our results suggest that each aspect of the benefit
change--promotion of in-network specialty providers, reducing
copayments, and a company-wide effort to destigmatize
mental health treatment--played a nearly equal part in
increasing the number of outpatient visits per episode.
Conclusions: The benefit expansion at the company appeared
to be successful in improving outpatient mental health
treatment intensity.
Implications for Policy, Delivery, or Practice: The results
point to the important role that benefit designers can play in
improving access to mental health care. There is longstanding and substantial data to demonstrate that outpatient
mental health services are effective. There is additional
evidence that demonstrates that lost productivity due to the
symptoms of mental illness is one of the highest healthrelated costs that businesses incur. Thus, while this study
does not assess the potential economic impact of the
adoption of the present approach, there is every reason to
believe that enhancing engagement in treatment has
associated costs but has the potential for more significant
savings for any large employer.
Primary Funding Source: NIMH
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Effectiveness of a Case Management Program for High
Risk Patients with Co-morbid Medical, Psychiatric, and
Substance Use Disorders
Joann Albright, Ph.D., Alexander R. Rodriguez, M.D.
Presented By: Joann Albright, Ph.D., Senior Vice President,
Quality, Outcomes, & Research, Quality, Outcomes, &
Research, Magellan Health Services, Inc., 6950 Columbia
Gateway Drive, Columbia, MD 21046; Tel: (410) 953-2301; Fax:
(410) 953-5210; Email: JMAlbright@magellanhealth.com
Research Objective: To use standardized measures to assess
functional health status and productivity outcomes for highrisk members in a managed behavioral health care
organization’s intensive case management program, and
estimate the financial impact of such outcomes to employers.
Study Design: Members are identified for program
participation through multiple portals, including claims or
authorization data, referral from the behavioral healthcare
organization’s care managers or practitioners, or staff of a
partnering health plan. Program components include initial
assessment of health, treatment, and case management
needs; regularly scheduled supportive interventions including
review of treatment goals, compliance with treatment, and risk
of harm or relapse; patient education and empowerment;
coordination of care among medical and behavioral
practitioners, and patient-specific feedback to practitioners
involved in the member’s care. Clinical outcomes are
measured by self-report using the Short-Form-12® Health
Survey and proprietary questions on productivity. Measures
from the SF-12® are Physical Component Summary Score
(PCS-12) and Mental Component Summary Score (MCS-12).
Data are collected at intake and discharge and at specified
intervals during participation.
Population Studied: Population consists of all members of
the behavioral healthcare organization who meet criteria for
entry into the program. Criteria consist of high-risk status,
including medical/psychiatric or substance use/psychiatric comorbidity, frequent re-admission to inpatient or residential
treatment, and risk of harm; and age above 14 years.
Principal Findings: Data for members in the program
between July 2002 and December 2004 yielded a total of
4,430 members with 1,019 of these completing both intake
and discharge measurements. More than 93.6 percent of
participants (954/1019) displayed improvement in functioning
as measured by overall SF-12® score between intake and
discharge. PCS-12 scores on the SF-12® improved by 56.3
percent and MCS-12 scores improved 81.7 percent between
intake and discharge. Productivity improved by 4.3 days as
measured by members’ self-report of average number of days
missed from work or school due to their condition.
Conclusions: Intensive case management interventions are
associated with significant improvements in physical and
mental health functioning for adults who meet criteria for
high-risk status, including medical/psychiatric co-morbidity,
substance abuse/psychiatric co-morbidity, and risk of harm.
Increases in functioning and gains in productivity for this
population have significant financial implications for
employers; using the U.S. Department of Labor’s 2003 figure
of $145/day for median daily earnings of full time workers, the
estimated average savings to an employer whose employee
received the intensive case management intervention
described in this presentation was $623.5 per employee. The
dollars saved by employers for the 1,019 members with intake
and discharge data was $635,347.
Implications for Policy, Delivery, or Practice: Intensive case
management interventions can yield favorable functional and
economic outcomes for patients and their employers or other
purchasers of health care. Policies and organizational cultures
that promote the use of intensive case management will
improve quality of life and reduce costs.
Primary Funding Source: No Funding
●Access to Support Services in Opioid Treatment
Programs
Nancy Berkman, Ph.D., MLIR, Wendee Wechsberg, Ph.D.,
Herman Diesenhaus, Ph.D.
Presented By: Nancy Berkman, Ph.D., MLIR, Research
Analyst, Health, Social and Economics Research, RTI
International, 3040 Cornwallis Road, PO Box 12194, Research
Triangle Park, NC 27709-2194; Tel: (919)541-8773; Fax:
(919)990-8454; Email: berkman@rti.org
Research Objective: In this study, we examined whether a
patient's receipt of specific treatment-related and support
services was related to how they were offered by the opioid
treatment program (OTP). Services include general medical
care, AIDS-related medical care and educational, vocational,
financial,legal, and housing/shelter assistance. We compared
the effect of offering a service on-site, at another of the
program's sites, through formal linkages or informal linkages
relative to not at all.
Study Design: We conducted descriptive and multivariate
analyses. Our multivarite analysis used a hierarchical linear
model (random effects model). This allowed us to control for
patients' receipt of services at the same OTP not being
independent of each other.
Population Studied: The population studied is OTP patients.
We obtained data from a 2001 nationally representative followup sample of OTP sites (N=144) that participated in the
Center for Substance Abuse Treatment (CSAT) sponsored
Evaluation Project. We used data provided by the Site
Director on the OTP as a whole, including its organization and
services offered, and survey responses from patients collected
from a random sample of up to 50 patients per site
distributed across dosing times (N=5,776).
Principal Findings: Only a small percentage of patients
received any of the treatment-related or support services
studied in the past three months. In relation to treatment
services, patients were most likely to have received general
medical care (28%). In relation to support services, they were
most likely to have received educational assistance (22%) and
least likely to have received legal or housing/shelter assistance
(8% and 7%, respectively).
Most services were offered by OTPs through some
arrangement (from onsite to informal referral). General
medical care, AIDS-related medical care, and educational,
vocational, and housing/shelter assistance were offered by
greater than 90% of OTPs. Less common were financial and
legal assistance, offered by less than 80% of OTPs.
None of these services were very commonly offered on-site by
OTPs. However, patient receipt of general medical care, AIDSrelated medical care, vocational and financial assistance was
significantly and positively related to it being offered on-site.
A second OTP characteristic that was significantly associated
with patient receipt of these services is ownership. In four of
the seven service areas (general medical care and educational,
vocational and financial assistance) receiving treatment at a
nonprofit or public OTP was related to an increase in the odds
of a patient receiving the service through the OTP.
Conclusions: Even though treatment-related and support
services have been shown to improve outcomes among OTP
patients, they are not being receieved by many patients. Sites
tend to rely on linkage arrangements with other organization
for providing this care but it rarely has a significant effect. A
more effective approach is providing the care directly.
However, even after controlling for the arrangement that
OTPs used to provide services, it appears that being at a
nonprofit and public OTPs provides extra protection that a
patient will receive these services.
Implications for Policy, Delivery, or Practice: In the new
area of OTP accreditation, additional emphasis is on the
quality of care provided by OTPs. However, just the offer of a
service may not be enough to reliably ensure that it is going to
be received by many patients. Instead, standards need to be
based on receipt of care.
Primary Funding Source: CSAT
●Nurse Administered, Patient-Tailored, Telephone
Intervention for Blood Pressure Control
Hayden Bosworth, Ph.D., Maren Olsen, Ph.D., Tara Dudley,
M.Stat, Mary Goldstein, M.D., MS, Melinda Orr, MEd, Eugene
Oddone, M.D., MHSc
Presented By: Hayden Bosworth, Ph.D., Associate
Director/Associate Research Professor, HSRD/Medicine,
Durham VAMC/Duke University, Durham VAMC (152), 508
Fulton Street, Durham, NC 27705; Tel: (919)668-0300; Fax:
(919)416-5839; Email: Hayden.Bosworth@Duke.edu
Research Objective: A randomized controlled trial involving a
nurse-administered patient-tailored intervention is being
conducted to improve BP control.
Study Design: Veterans with hypertension from an outpatient
primary care clinic completed a baseline assessment and were
randomly allocated to either a nurse-administered intervention
or to usual care. Intervention patients receive the tailored
intervention bi-monthly for two years via telephone; the goal of
the intervention is to promote adherence with medication and
improve health behaviors. Patient factors targeted for
intervention include perceived risk of hypertension, memory,
literacy, social support, patients’ relationship with their health
care provider, side effects of therapy, pill refill, missed
appointments, diet, exercise, alcohol use, and smoking.
Population Studied: 588 veterans were randomized (294 to
the nurse telephone intervention and 294 to usual care). At
baseline, patients were on average 63 years old, 40% were
African-American, and were taking an average of 2.3
hypertensive medications. Baseline BP values showed that
only 43% were in control based on JNC 6 criteria (<140/90
mm hg for non-diabetics and <130/ 85 mm hg for diabetics).
Principal Findings: Of the 274 patients randomized to the
behavioral intervention, 88% of the sample has been followed
for at least 17 months (only 4% have dropped out of the
study). The average length of time to administer each
intervention phone call was 3.7 minutes (range 1-40 minutes).
After 12 months of follow-up, BP control improved by 18% in
the nurse intervention group. Less improvement was seen in
the control group (n=274); BP control only increased by 10%.
There was no difference in the number of primary care visits
over the 60 weeks (both groups had an average of 3 PCP
visits). Patients were also satisfied with the content and
process of the calls; 61% reported having the nurse call every
other month has helped them control their BP, 85% would
recommend the nurse intervention to a friend, 91% reported
being satisfied with receiving regular nurse calls.
Conclusions: This telephone-based intervention designed to
enhance adherence with prescribed hypertension regimen was
easy to implement and at 12-months improved BP control by
8% relative to a control group.
Implications for Policy, Delivery, or Practice: While the
main outcome of this on-going clinical trial will be 24-month
BP control, BP improved at 12-months. In addition, patients
viewed the intervention favorably.
Primary Funding Source: VA
●Anxiety and Depression in the Etiology of Chronic Pain:
Results from a Longitudinal Cohort Study of Trauma
Patients
Renan Castillo, MS, Stephen T. Wegener, Ph.D., Ellen J.
MacKenzie, Ph.D., Michael J. Bosse, M.D., LEAP Study Group
Presented By: Renan Castillo, MS, Doctoral Student, Health
Policy and Management, Johns Hopkins University Bloomberg
School of Public Health, 624 North Broadway, Room 544,
Baltimore, MD 21205; Tel: (410) 614-4024; Fax: (410) 6142797; Email: rcastill@jhsph.edu
Research Objective: While chronic pain can often be linked to
prior physical trauma, its etiology is still poorly understood.
Numerous studies have shown pain correlates with
depression and anxiety, and a causal relationship has been
hypothesized. The direction of this relationship, however, is
not clear: both the hypothesis that pain is causally related to
psychologic distress and that psychologic distress is causally
related to pain have received wide circulation, though neither
of these links has been empirically demonstrated. The
objective of this analysis is to characterize the longitudinal
relationship among pain, anxiety and depression in a cohort of
trauma survivors.
Study Design: Patients (N=327) from a larger study of severe
leg trauma were followed at baseline, 3, 6, 12, and 24 months
post-injury using a visual analogue pain scale and the
depression and anxiety scales of the Brief Symptom Inventory.
Structural Equation Modeling (SEM) techniques were used to
study antecedent-consequence relationships between these
three sets of longitudinal variables.
Population Studied: Patients in the current analysis
constitute a subgroup of a larger study conducted to assess
the outcomes of amputation or reconstruction following limbthreatening lower extremity trauma. Patients 16 to 69 years old
were recruited into the study during the index admission at
one of eight level I trauma centers for treatment of high
energy trauma below the distal femur.
Principal Findings: Pain, anxiety and depression at all four
time points were placed into a single structural model, and
different causal relationships between anxiety, depression and
pain were tested in this setting.. A number of model fit
measures indicated that the final structural model was an
excellent fit for the data (Adjusted Goodness of Fit Test =
0.93; Root Mean Square Error of Approximation = 0.03). Pain
at three months was significantly predictive of depression at
six months (p=0.002). Pain at six months was significantly
predictive of both anxiety and depression at twelve months
(p=0.002 and p=0.04, respectively). At the latter time points,
this pattern was reversed, with anxiety at twelve months, but
not depression, significantly predicting pain level at 24
months (p<0.001).
Conclusions: The results support the hypothesis that in the
early phase following trauma, pain is a significant predictor of
anxiety and depression. In the late (or chronic) phase,
however, it is anxiety that drives pain level. These results
suggest anxiety may play a role in the etiology of chronic pain.
Implications for Policy, Delivery, or Practice: Chronic pain
is one of the leading causes of disability in the United States,
affecting as many as 50 million Americans. The results of this
study point to a number of important implications for the
delivery of services to this population in the post-acute and
early chronic stage post trauma. Specifically, the results
suggest that pain in the months following trauma should be
treated early and aggressively, as it may have longer term
psychologic consequences. Similarly, the treatment of chronic
pain years following trauma may need to include interventions
to address the patient’s psychologic distress.
Primary Funding Source: National Institutes of Health
●Evaluating a Statewide Tobacco Prevention and
Cessation Initiative
Matthew Chinman, Ph.D., John Engberg, Ph.D., David Dausey,
Ph.D., Donna Farley, Ph.D.
Presented By: Matthew Chinman, Ph.D., Behavioral Scientist,
RAND Corporation, 1776 Main Street, PO Box 2138, Santa
Monica, CA 90407-2138; Tel: (310) 393-0411; Fax: (310) 3934818; Email: Matthew_Chinman@rand.org
Research Objective: Arkansas is one of the few states that
allocated all of its funds from the master settlement
agreement to address health-related issues. A key element,
which receives one-third of the Arkansas Tobacco Settlement
funding, is the statewide Tobacco Prevention and Education
Program (TPEP), run by the Arkansas Department of Health
(ADH). This paper reports on the evaluation of TPEP’s
implementation and effects on health outcomes during its
first two years.
Study Design: TPEP implemented the nine program
components recommended by the CDC’s guidelines for
statewide tobacco control (community programs, tobaccorelated disease programs, school programs, statewide
programs, enforcement, counter-marketing, cessation
programs, surveillance, administration). The FORECAST
system of process evaluation was used to assess
implementation by monitoring completion of various program
milestones specified by TPEP’s model of action. Stakeholders
were interviewed to document their perspectives on the
program’s effectiveness. The outcome evaluation examined
statewide trends in cigarette sales and smoking behaviors
since implementation of TPEP. Spending was monitored to
assess appropriate fiscal management and fidelity to the CDC
spending guidelines. The evaluation has emphasized local
collaboration in its design and implementation and regularly
provides performance feedback to the program.
Population Studied: For the process evaluation, interviews
were with key program staff and opinion leaders. For the
outcome evaluation, populations were adult and youth
Arkansans, with samples for the Behavioral Risk Factor
Surveillance System and the Youth Risk Behavior Surveillance
System (statewide surveys coordinated by the CDC).
Principal Findings: The process evaluation showed that the
TPEP successfully launched all nine program components
recommended by the CDC, using a community-based
approach to ensure local involvement in interventions. For the
first year of the program, the outcome evaluation could not yet
detect evidence of change in youth and adult smoking rates or
cigarette sales, but small changes in smoking behaviors were
found for pregnant women, young adults (age 18 to 25), and
teen mothers. The spending analyses revealed that across the
first 2 years, between 11-22% of TPEP funds were diverted by
the state legislature to non-tobacco areas and that most of the
nine program components were under-budgeted according to
the CDC spending guides for statewide tobacco control.
Conclusions: While still too early to determine effects on
smoking behavior, the TPEP has established a strong
foundation for its statewide tobacco control program and is
mostly consistent with best practices guidelines developed by
the CDC. The TPEP’s progress continues to be tempered by
reductions in funding and the lack of political support for
some effective tobacco control strategies such as higher taxes
and smoking bans in public areas.
Implications for Policy, Delivery, or Practice:
Comprehensive statewide tobacco control programs have
been shown to be effective in other states. TPEP has the
potential to achieve similar outcomes and be a model of
statewide tobacco control if it can secure the needed funding
and political support. The evaluation of TPEP is innovative in
that it tracks implementation, outcomes, spending, and policy
impact while also incorporating significant input from local
stakeholders.
Primary Funding Source: Arkansas Tobacco Settlement
Commission
●Reliability of Self-Reported Behavioral Health Services
Utilization and its Implications for Economic Evaluations
Sukyung Chung, MHP, Elizabeth Jackson, Ph.D., Marisa
Domino, Ph.D., Joseph Morrissey, Ph.D.
Presented By: Sukyung Chung, MHP, Graduate Student,
Department of Health Policy and Administration, University of
North Carolina at Chapel Hill, 1103B McGavran-Greenberg
Hall, CB#741, Chapel Hill, NC 27599-7411; Tel: (408)746-0916;
Email: sukyungc@email.unc.edu
Research Objective: Self-reported services utilization data
capture information on a broader range of services than
administrative records kept by health care payers or service
providers. In behavioral health services research where
patients use a variety of service domains outside of usual
medical care, self-reporting may provide more accurate and
complete information on overall service utilization. The
objectives of our study are: 1) to examine test-retest reliability
of self-reported service use received by women with behavioral
health problems; 2) to identify factors affecting reliability of
reported service types and intensities; and 3) to assess
impacts of inconsistency in reporting on economic
evaluations.
Study Design: The test-retest data examined in this study
come from the Women, Co-occurring Disorders, and Violence
Study. We first analyzed test-retest reliability of self-reported
service use: any service use, service-type specific and facility
specific intensity of service use, and contents of service
(mental health, substance abuse, and trauma) for each service
type. Kappa coefficients and intraclass-correlation coefficients
(ICC) were used for dichotomous and continuous measures,
respectively. Measures were considered as reliable when
coefficients were above 0.4. Second, we estimated a logit
model of any service use and an OLS model of intensity of
services to identify determinants of consistent responses with
repeated measures. Factors examined were service type,
psychiatric symptom severity, intervention status (intervention
vs. control), and relevant demographic characteristics. Finally,
we compared the overall services costs and the incremental
cost of intervention estimated using the test data and retest
data to assess robustness of economic evaluation with
repeated measures.
Population Studied: The Women, Co-occurring Disorders,
and Violence Study is a quasi-experimental study conducted in
9 sites nationwide during 2001 and 2002. Study subjects were
women aged 19-59 with either a psychiatric or substance
abuse diagnosis and a trauma history. A retest interview was
given within 12 days from the baseline assessment to 186
participants from intervention and comparison group across 9
sites.
Principal Findings: Test-retest reliability of service use was
high (kappa=0.68 – 0.94) for any use and generally good
(ICC=0.46 – 0.99) for intensity of services. However, reliability
of patients’ perceptions on contents of services received
during individual and group counseling were fairly low
(kappa=-0.04 – 0.66). Second, consistency of reports varied
across service types. Patients reported hospital use more
consistently than outpatient-based services (odds ratio=0.28 –
0.32). Psychiatric symptoms severity, intervention, and
demographic factors did not affect consistency in reporting.
Finally, overall costs and incremental costs of intervention did
not differ across test and retest data.
Conclusions: Self-reports of health services utilization are
generally reliable and can be a useful data source for
economic evaluations. Considering the severity of mental
conditions among study participants, the result should be
interpreted as a conservative boundary. Future research
should explore the reliability of self-reported service use
among the general population.
Implications for Policy, Delivery, or Practice: Self-reported
services use data is not only comprehensive in scope but also
reliable, and can be recommended as a primary data source in
behavioral health services research.
Primary Funding Source: Other Govt, Substance Abuse and
Mental Health Services Administration (SAMHSA)
●All Capitated Mental Health Systems Are Not Alike:
Effects of Organizational Structure on Utilization of
Inpatient Psychiatric Care
Janet Coffman, MA, MPP
Presented By: Janet Coffman, MA, MPP, Graduate Student
Researcher, Health Services & Policy Analysis, University of
California, Berkeley, 1068 Kains Avenue, Apartment 8, Albany,
CA 94706; Tel: (510)524-9851; Fax: (510)643-6981; Email:
janetmc@berkeley.edu
Research Objective: In many states, Medicaid beneficiaries
receive mental health services through capitated systems of
care. Most studies of capitation of mental health services find
that capitation reduces total expenditures, primarily by
reducing utilization of inpatient psychiatric care. Few studies
of Medicaid capitation have examined variation in the
organizational structure of capitated systems, because most
states have implemented a single system. This study
examines the effects of variation in the organizational
structure on inpatient utilization by analyzing data from
Colorado, one of the few states to implement two different
types of capitated systems.
Study Design: This cross-sectional, quasi-experimental study
examines use of inpatient psychiatric care by adult Medicaid
beneficiaries in Colorado during the second year following the
implementation of capitation (fiscal year 1997). Colorado has
a mental health “carve out” under which full-risk capitation
contracts are awarded such that a single entity is responsible
for mental health services in a designated geographic area.
During the study period, providers in some areas of the state
continued to receive fee-for-service reimbursement. The
treatment groups consist of Medicaid recipients residing in
areas served by the two types of capitated systems: 1) direct
capitation of community mental health centers (CMHCs), and
2) a joint venture between CMHCs and a for-profit managed
behavioral health organization (MBHO). The comparison
group consists of Medicaid recipients residing in the fee-forservice areas. Three measures of inpatient utilization are
analyzed: probability of hospitalization, length of stay per
admission, and inpatient days per user. The models control
for consumers’ age, sex, diagnosis, and hospitalization during
the previous year. Logistic regression is used to estimate
probability of hospitalization and linear regression is used to
estimate length of stay and inpatient days.
Population Studied: The study examines adult Medicaid
beneficiaries with mental illness (based on DSM-IV diagnostic
codes) who utilized mental health services during fiscal year
1997. Data were obtained from Medicaid fee-for-service
claims and encounter data on utilization in capitated areas.
Principal Findings: Preliminary results suggest that both
types of capitated systems reduced utilization of inpatient
care, but that they achieved reductions in two different ways.
Consumers served by the directly capitated CMHCs had lower
probability of hospitalization than consumers in fee-for-service
areas (-0.95, P<0.01), whereas consumers served by the
CMHC-MBHO joint venture had shorter length of stay and
fewer inpatient days per user relative to fee-for-service
consumers (both 0.4, P<0.001).
Conclusions: The two different types of capitated systems
used different techniques to control inpatient utilization.
These differences may reflect variation in either the
organizational structures or strategies of the two systems.
Interviews conducted with managers and clinicians in the two
capitated systems suggest that the directly capitated CMHCs
focused on creating community-based alternatives to inpatient
care, whereas the CMHB-MBHO joint venture concentrated
on reducing length of stay. Further research is needed to
determine whether the differences in utilization management
affect consumer outcomes.
Implications for Policy, Delivery, or Practice: State
policymakers are once again facing great pressure to control
Medicaid expenditures. They should be cognizant of the
potential effects of providers’ organizational strategies and
structures on the implementation of cost-containment
policies.
Primary Funding Source: No Funding
●Body Image Disturbances among Hispanic Women in
Sexually Intimate Relationships
Noris De Jesus, Bachelors, Masters
Presented By: Noris De Jesus, Bachelors, Masters, graduate
student, Couple and Family Therapy, Couple and Family
Therapy, 1530 Commonwealth Avenue, Bronx, NY 10460; Tel:
(646) 541-9383; Email: noris_dejesus@yahoo.com
Research Objective: The purpose of the following proposal is
to find out if Hispanic women suffer from body image
disturbances and if there is a relationship between body image
disturbances and sexual intimacy.
Study Design: Participants in the proposed study would be
given questionnaires to measure for body dissatisfaction,
extreme dieting and the discomfort of being nude in front of
partner. To measure for body dissatisfaction, the participants
would be given the Stunkard, Sorensen and Schulsinger (1983)
9-point pictorial body image scale. To measure for extreme
dieting, they would be given the Gamer & Garfinkel (1979)
Eating Attitudes Test-26 and the body image selfconsciousness scale that focuses on self-perception of one’s
body during intimacy with partner (Wiederman, 2000).
Population Studied: The participants would be Hispanic
(Puerto Rican, Dominican, Mexican and Cuban) women, from
the ages of 18 to 60. They would be living in New York City in
the boroughs of the Bronx and Manhattan.
Principal Findings: That Hispanic women do suffer from
body image disturbances and that there is a relationship
between body image disturbances and difficulties during
sexual intimacy with their male partners.
Conclusions: Research must be conducted in many
populations. Limiting research to only one population limits
the capacity of the mental health fields. Recommendations for
future studies, in regards to the Hispanic population,
concerning body image disturbance and sexual intimacy must
be considered. The present proposal is indicative of such a
need.
Implications for Policy, Delivery, or Practice: Body image
disturbances and sexual intimacy difficulties have to be taken
into consideration by Couple and Marriage Therapists, when
they treat Hispanic couples and families. The field of Couple
and Marriage Therapy, as do other mental health fields, must
continue to acknowledge that the United States is diversifying
and that what may cause problems or conflict in a White
couple or family, might also cause difficulties in a Hispanic
household.
Primary Funding Source: No Funding
●Patterns of Mental Health Medication Use in Individuals
With Mental Health Problems and Co-morbid Alcohol
Dependence
Mark Edlund, M.D., Ph.D., Katherine M. Harris, Ph.D.
Presented By: Mark Edlund, M.D., Ph.D., Assistant Professor,
Psychiatry, University of Arkansas for Medical Sciences, and
Central Arkansas Veterans Healthcare System, 2200 Fort
Roots Drive, North Little Rock, AR 72114; Tel: 501-257-1712;
Fax: 501-257-1718; Email: edlundmarkj@uams.edu
Research Objective: To investigate patterns of mental health
medication use and perceived effectiveness of treatment with
mental health medications among mental health care users
with and without alcohol dependence.
Study Design: Secondary data analysis of a large, nationally
representative survey. The survey is designed for the primary
purpose of estimating the prevalence of illicit drug, alcohol,
and tobacco use in the United States. We calculated the
percentage of alcohol-dependent patients receiving a mental
health medication, and compared this with the percentage of
non-dependent patients receiving a mental health medication;
investigated patient-reported effectiveness of mental health
treatment among alcohol-dependent patients receiving a
mental health medication, and those not receiving a
medication; and investigated patient-reported effectiveness of
treatment in alcohol-dependent and non-dependent patients
receiving mental health medications.
Population Studied: Data are from the 2001-2003 National
Survey on Drug Use and Health. We limited our analyses to
individuals receiving mental health treatment in the past year
(n=11,872).
Principal Findings: There were no statistically significant
differences in the rate of mental health medication use
between those with and without alcohol dependence, 76.2%
and 75.9% respectively (t=0.11, p=0.91). Among alcoholdependent patients, those receiving a mental health
medication were significantly more likely to report that mental
health treatment helped a lot or a great deal (OR=2.87, 95%
CI=1.57, 2.56, p<0.001) than those not receiving a medication.
Among individuals taking mental health medications, there
were no statistically significant differences in patient ratings of
effectiveness of treatment between dependent and nondependent respondents.
Conclusions: Most alcohol-dependent individuals in mental
health treatment received a mental health medication, despite
a lack of guideline support. The large majority of individuals
with alcohol dependence receiving a mental health medication
reported that mental health treatment was effective.
Implications for Policy, Delivery, or Practice: Our results
raise two important questions. First, are mental health
medications effective in reducing mental health symptoms in
patients with comorbid substance disorders? Clearly this
question deserves further study in clinical trials. The
possibility that they are effective presents a puzzle with
important implications for clinical management that can only
be resolved through research on physicians’ prescribing
decisions: Are physicians prescribing to dependent patients
because they are unaware of substance use disorders or
because they believe the medications are effective in patients
with co-occurring disorders, despite lack of a strong evidence
base or professional consensus? In other words, are clinicians
doing the right thing by doing the wrong thing or is this an
example where clinical researchers are lagging behind their
colleagues in the field?
Primary Funding Source: VA
●Integration of Behavioral Risk Screening in Urban
Reproductive Health Care Centers Serving Latinas
Samantha Garbers, MPA, Sarah Blust, MSW, MPH, Sabina
Hirshfield, Ph.D., Natalie Tobier, MSW, MPH, Katherine
Miller, MPA, Mary Ann Chiasson, DrPH
Presented By: Samantha Garbers, MPA, Research Associate,
Research & Evaluation Unit, Medical & Health Research
Association of New York City, Inc. (MHRA), 40 Worth Street,
Suite 720, New York, NY 10013; Tel: (212)285-0220 x119; Fax:
(212) 385-0565; Email: sgarbers@mhra.org
Research Objective: MHRA has implemented a project to
develop, pilot and integrate routine behavioral risk screening
of patients seeking reproductive health care services through
eight MIC-Women’s Health Care Services centers in New York
City. A standardized tool consisting of screening questions to
identify patients with behavioral risks– smoking, symptoms of
depression and anxiety, alcohol and substance use, and
intimate partner violence – was developed. The project also
includes training of center staff and technical assistance from
experts in behavioral health. A project evaluation is
measuring its ability to identify and appropriately refer women
in need of behavioral and mental health services.
Study Design: The proportion of patients who screened
positive for any of the risk factors at baseline and after pilot
implementation of the screening project are compared, using
Chi-square tests.
Population Studied: To date, 237 of a planned 400 baseline
records at 8 centers have been analyzed, as have all records of
200 prenatal and family planning patients screened during the
pilot at one center (May-September 2004). Because of the
ethnic diversity of the patient population, this analysis
includes only Latina patients (baseline n=138; pilot n=179).
Among the Latinas screened in the pilot phase, 55% had less
than a high school degree, 65% were primary Spanish
speakers, and 70% were foreign-born.
Principal Findings: At baseline, patients were screened for
behavioral and mental health risks according to standard
clinical practice defined by the American College of Obstetrics
& Gynecology. With the pilot implementation of a
standardized screening protocol and ongoing staff training,
the project has significantly increased health care providers’
identification of women in need of behavioral and mental
health assessment, referral, and treatment. Before
implementation, 10.9% of Latinas screened positive for any
risk factor, compared to 28.5% after pilot implementation
(p<.001). The prevalence of current alcohol use and current
drug use were low at both times. Significant increases were
detected after pilot implementation for symptoms of
depression, anxiety, or desiring counseling (3.6% to 18.4%,
p<.001) and smoking (2.2% to 7.8%, p=.05). The proportion
reporting a history of intimate partner violence also increased
(7.2% to 12.8%, p=.15).
Conclusions: For many women -- particularly MIC’s patients
who are predominantly uninsured, recent Latina immigrants -reproductive health is often the initial and sole point of
contact with health care. Therefore, screening, identification
and treatment initiatives for behavioral and mental health
among our patient population are imperative. Evaluation data
indicate that the project has significantly increased providers’
identification of women in need of referral or services for both
mental health and behavioral health risks.
Implications for Policy, Delivery, or Practice: Integrating
behavioral and mental health screening into reproductive
health care presents an opportunity to reach a population that
may not otherwise access mental health services. Evaluation
will continue to guide the project’s identification of women in
need of assessment and referral, as well as the management
and referral of patients once they have been identified through
the screening process.
Primary Funding Source: HRSA
●Use of Complementary and Alternative Therapies:
Results from a Multisite Multistate Survey
Kelly Gebo, M.D., MPH, Joshua Josephs, Richard Moore,
M.D., MHS,
Presented By: Kelly Gebo, M.D., MPH, Assistant Professor of
Medicine and Epidemiology, Department of Medcine; Division
of Infectious Diseases, Johns Hopkins University School of
Medicine, Room 442, 1830 East Monument Street, Baltimore,
MD 21215; Tel: (410)502-2325; Fax: (410)955-7889; Email:
kgebo@jhmi.edu; tcottrell@jhmi.edu
Research Objective: Use of complementary and alternative
therapies (CAM) is expensive and are known to interact with
several components of HAART. We quantified use of CAM
and identified factors associated with use of CAM among
HIV+ patients in primary care.
Study Design: Cross-Sectional survey of HIV+ patients who
participated in face-to-face interviews at 14 HIV primary care
sites that are part of the HIV Research Network in 2003. CAM
was defined as any use of any alernative therapy including
acupuncture, herbal use, massage therapy or other alternative
therapies. Logistic regression was used to determine sociodemographic and clinical factors associated with use of CAM.
Population Studied: 951 patients in primary HIV care at 14
care sites: These sites are located in the Eastern (6),
Midwestern (3), Southern (2), and Western U.S. (3). Seven of
these sites have academic affiliations; 7 are community-based.
The median sample size per site was 59 patients (range: 38 to
172 patients).
Principal Findings: The majority of the participants were
male (68%) and of minority ethnicity, African American
(51.7%) and Hispanic (13.7%). Median age was 46 years
(range 20-85). The majority received HAART (69%). HIV risk
factors included Male to male sex (39.3%) heterosexual
transmission (27.4%) or injection drug use (14.4%). 15.7% of
patients used any CAM in the 6 months prior to the interview,
and of these 67% were on HAART. In multivariate regression
adjusting for site, factors associated with any CAM use
included: high school or junior college education (Adjusted
Odds Ratio (AOR) 1.24 95% CI .74-2.08) college education
(AOR 2.90 95% CI 1.56-5.40), current (AOR, 1.78 95% CI 1.043.05) or former illicit drug use (AOR, 1.86 95% CI 1.08-3.21),
any inpatient psychiatric admission or visit to psychiatry(AOR
2.78, 95% CI 1.85-4.17) and cd4 count <50 (AOR 1.56, 95% CI
1.04-2.34). Patients who lived with others (AOR 0.53, 95% CI
.33-.86) were less likely to use CAM than those who lived
alone.
Conclusions: CAM use is common among HIV patients,
particularly those who use or have used drugs, use mental
health services or who have advanced immunosuppression or
more education. Patients who lived with others were less
likely to use CAM than those who live alone.
Implications for Policy, Delivery, or Practice: CAM services
add to the cost of care and can potentially interfere with
known effective antiretroviral therapies. Patients should be
encouraged to be honest about their use of CAM to help
providers improve health care delivery and health care
providers need to appropriately assess for use of CAM among
their patients. Finally providers need to learn more about the
interactions of CAM with traditional HIV therapies and the
effectiveness and side-effects of CAM.
Primary Funding Source: AHRQ, HRSA, SAMHSA, OAR
●The Liver Health Initiative: Coordinating Hepatitis
Prevention and Treatment Referral through a Substance
Use Disorders Clinic
Hildi Hagedorn, Ph.D., Mark Willenbring, M.D., Eric
Dieperink, M.D., Samuel Ho, M.D., Nancy Pexa, MA, Debra
Dingmann, RN
Presented By: Hildi Hagedorn, Ph.D., Implementation
Research Coordinator, Minneapolis VA Medical Center,
Departmanet of Psychiatry, VA Quality Enhancement Research
Initiative, 1 Veterans Drive (116A9), Minneapolis, MN 55417;
Tel: (612)467-3875; Fax: (612)725-2013; Email:
hildi.hagedorn@med.va.gov
Research Objective: Veterans with substance use disorders
(SUDs) are the veteran group with the highest risk for viral
liver disease and the highest prevalence of hepatitis C.
Integrating hepatitis prevention and referral services into SUD
treatment programs would provide a unique opportunity to
target services to this high-risk group. The Liver Health
Initiative represents collaboration between the Minneapolis
VA Medical Center Addictive Disorders Service (ADS), the VA
Quality Enhancement Research Initiative Substance Use
Disorders Center (QUERI-SUD), and the Minneapolis VA
Hepatitis C Resource Center. The purpose of the Liver Health
Initiative is to develop a protocol and implementation tools
for: 1) improving testing for hepatitis C and implementing
universal testing for hepatitis A and B infection and immunity,
2) providing comprehensive structured patient education on
liver health, 3) beginning a hepatitis A and B immunization
program for high-risk patients lacking immunity, and 4)
increasing rates of successful referral to the hepatitis clinic for
hepatitis C positive patients.
Study Design: A chart audit of 100 consecutive ADS intakes
was completed to document hepatitis A, B, and C screening
rates, whether feedback on screening results was
documented, and whether patients positive for hepatitis C
were referred for treatment. A survey of 71 current ADS
patients was also completed to assess patient interest in
hepatitis education and patient preferences for various
teaching methods. The chart audit and survey were used to
identify service improvement goals. In July, 2004, a
stakeholder group was convened to meet weekly to develop
procedures and tools for meeting service improvement goals.
Group members included ADS leadership and staff from
multiple disciplines including psychology, nursing, and
administation as well as expert consultants drawn from the
QUERI-SUD and Hepatitis C Resource Centers.
Population Studied: Veterans presenting to the Minneapolis
VA Medical Center ADS clinic for SUD treatment.
Principal Findings: In January, 2005, six months following the
first meeting of the stakeholder group, all veterans presenting
for treatment in ADS began receiving screening for hepatitis A,
B, and C infection and hepatitis A and B immunity. Individual
nursing follow-up appointments were scheduled with all
veterans to review their screening results, offer them
vaccinations for hepatitis A and B which are now administered
on-site in the ADS clinic, and refer them to the hepatitis C
specialty clinic as appropriate. In addition, all veterans
presenting for treatment are scheduled into a one-hour liver
health educaiton group. By June, 2005, additional outcome
data will include patient satisfaction data as well as a follow-up
chart audit to document service improvements.
Conclusions: Hepatitis screening, prevention, education, and
treatment referral services have been successfully integrated
into a VA SUD treatment clinic with minimal disruption to
clinic functioning.
Implications for Policy, Delivery, or Practice: Development
of a liver health program within the Minneapolis VA ADS clinic
not only provides a template for designing such a program but
has also lead to the development of a variety of patient and
provider educational tools. These protocols, procedures, and
tools will be used to promote implementation of liver health
services throught VA SUD treatment.
Primary Funding Source: VA
●Evaluation of a Program Integrating Behavioral Health
Providers into Primary Care
Daniel Harris, Ph.D., John LeFavour, Ph.D.
Presented By: Daniel Harris, Ph.D., Senior Project Director,
Center for Healthcare Research, The CNA Corporation, 4825
Mark Center Drive, Alexandria, VA 22311; Tel: (703) 824-2283;
Fax: (703) 824-2511; Email: harrisd@cna.org
Research Objective: Current literature suggests that
integrating behavioral health providers into primary care can
cost effectively enhance patient care. We evaluated a two-year
multi-site demonstration program that introduced a
“behavioral health consultant” (BHC) into primary care clinics
in a staff model managed care system, and assessed the
program’s implementation process and outcome performance
at each site to identify how well the program achieved its goals
and what factors facilitated and hindered program success.
Study Design: A cadre of psychologists and social workers,
briefly trained in providing primary behavioral health care,
were introduced into several primary care clinics located along
the east coast of the US and in Southern Europe. Using
available administrative data, project-specific primary data,
interviews, and site visits, we monitored the implementation
of the program between January 2003 and February 2004 in
three cohorts of clinics, and measured program performance
and impact through December 2004 against the program’s
logic model and stated goals. Process evaluation focused on
program implementation, fidelity, and output at each
demonstration site. Product outcome evaluation focused on
effectiveness and impact on patients and the participating
clinics, and utilized a quasi-experimental design comparing
demonstration site performance with that of matched
comparison non-demonstration sites over time.
Population Studied: Patients and providers at seven primary
care clinics in medical treatment facilities operated by the US
Navy for active duty service members, their dependent family
members, and retirees/survivors and their dependents.
Principal Findings: The program was successfully
implemented at six of the seven demonstration sites with
varying degrees of fidelity although long term sustainability
was not achieved at most sites and some implementation
issues faced by early implementing sites continued to pose
problems for later sites. Participants expressed general
satisfaction with the program although several issues affecting
both implementation and impact were identified. Program
output levels varied across sites depending in part on the
aggressiveness of the BHC, but intended target patient
populations were reached. Primary care providers typically
referred patients to BHCs more for traditional mental health
issues than for the behavioral or “health psychology” issues
the program intended to address. Program clinical and
financial outcomes, and impact on primary care and mental
health utilization patterns, generally met program goals but
were less substantial than expected and varied across sites.
Clear performance advantages at demonstration sites
compared to control clinics were difficult to detect.
Conclusions: Successful implementation of sustainable and
effective high fidelity programs is not a given and requires
much program planning and management as well as a stable
environment and primary care and mental health providers
who understand and are committed to the program logic.
Implications for Policy, Delivery, or Practice: Current
literature has shown that behavioral health programs
integrated into primary care can be effective. Our study
demonstrates that the ability to achieve and sustain these
results can vary by program site and identifies several factors
that can improve a program’s likelihood of success.
Primary Funding Source: Department of the Navy/Dept of
Defense
●Private Health Plans’ Management of Psychotropic
Drugs
Dominic Hodgkin, Ph.D., Constance M. Horgan, Sc.D.,
Deborah W. Garnick, Sc.D., Elizabeth L. Merrick, Ph.D., MSW,
Joanna Volpe-Vartanian, MS, LICSW
Presented By: Dominic Hodgkin, Ph.D., Associate Professor,
Schneider Institute for Health Policy, Brandeis University, 415
South Street, Waltham, MA 02454; Tel: (781) 736-8551; Fax:
(781) 736-3928; Email: hodgkin@brandeis.edu
Research Objective: In recent years, many insurers in the US
have introduced policies intended to control medication
utilization, often working with pharmacy benefits managers
(PBMs). These policies include coverage exclusions, prior
authorization requirements, and restrictions on first line use.
Another, more consumer-focused policy is the incentive
formulary, which places some medications on a ‘nonpreferred’ cost-sharing tier, subjecting them to substantially
higher copayments. These policies could potentially have
important effects on patients’ use of medications and health
outcomes, particularly if there is poor substitutability between
the drugs restricted and not restricted. Alternatively, if
patients find it difficult to switch medications, incentive
formulary approaches may confront them with substantial
out-of-pocket costs.
Our study documents the extent and stringency of private
health plans’ management of psychotropic drug use. We also
examine how stringency relates to plan characteristics, such as
plan size and pharmacy contracting arrangement.
Study Design: Using a telephone survey, we collected detailed
data on administrative and clinical aspects of behavioral
health care delivery from 368 commercial health plans in 60
US market areas, yielding national estimates of plan features
(83% response rate). This paper relies on the pharmacy
module, which asked about the coverage of each of 28
psychotropic medications, including the cost-sharing tier
placement and what restrictions applied. We asked about
coverage of novel drugs in four psychotropic drug classes:
antidepressants, anti-psychotics, drugs for attention-deficit
hyperactivity disorder (ADHD) and substance abuse. From
these data we construct measures of stringency at the level of
the drug class. Multivariate analyses are used to relate
restrictiveness to characteristics of the health plan.
Population Studied: Commercial health plans with managed
care products.
Principal Findings: 56% of plans report contracting with a
PBM. 84% of plans use formularies with 3 or more tiers, with
‘non-preferred’ medications placed on the costliest tier. 40%
of plans exclude at least one medication for substance abuse,
but plans rarely exclude medications in the other classes we
examine. Prior authorization and ‘fail first’ policies are rarely
applied to psychotropic drugs by these private plans (<10% of
plans). Placement on a non-preferred tier is the most
common type of restriction, used by two-thirds of plans for
antidepressants, anti-psychotics and ADHD drugs and 52%
for substance abuse medications. 47% of plans place 2 or
more novel antidepressants on the non-preferred tier, and
slightly fewer plans do so for newer antipsychotics and ADHD
drugs. The stringency of psychotropic drug management
relates to the plan’s size and market area characteristics.
Conclusions: Private health plans appear to rely chiefly on
high copayments to direct patients to certain medications.
This contrasts with public sector programs like Medicaid,
which rely more on prior authorization and ‘fail first’ policies.
Implications for Policy, Delivery, or Practice: To understand
privately insured patients’ access to behavioral health care,
one must examine the details of formularies, including which
drugs in each class are assigned to which cost-sharing tiers.
Primary Funding Source: NIAAA,
●Psychiatric Comorbidities and Patterns of Medical Care
Use for Patients with Generalized Anxiety Disorder in an
Integrated Delivery System
Mark C. Hornbrook, Ph.D., Dennis Revicki, Ph.D., Louis
Matza, Ph.D., Gregory C. Clarke, Ph.D.
Presented By: Mark C. Hornbrook, Ph.D., Chief Scientist,
Center for Health Research, Kaiser Permanente Northwest,
3800 North Interstate Avenue, Portland, OR 97227; Tel: (503)
335-6746; Fax: (503) 335-2428; Email:
mark.c.hornbrook@kpchr.org
Research Objective: To describe the comorbidities, treatment
patterns, and medical service utilization of patients with
Generalized Anxiety Disorder, and to assess the medical care
burden of this mental health condition.
Study Design: This study is a retrospective analysis of
medical care encounter and claims data from databases of a
large prepaid integrated delivery system in the Pacific
Northwest. We extracted data for the study participants from
the health plan’s computerized administrative and clinical
information systems for the calendar year.
Population Studied: Study patients were age 18 years or older
who met study criteria and were members of the health plan
continuously for the entire year. The sample size was 3,606
patients. Patients had at least two medical care encounters
during 2003 with GAD, ICD-9-CM code 300.02, or anxiety
state unspecified, ICD-9-CM code 300.00, or both. We
excluded patients with diagnoses of schizophrenia or other
psychosis, bipolar disorder, and mental retardation.
Principal Findings: The patient sample, 71 percent women,
included 25 percent with a diagnosis of major depressive
disorder, 12 percent with dysthymia, 23 percent with a
substance abuse disorder, 13 percent with panic disorder, 7.4
percent with social or other phobias, 4.8 percent with posttraumatic stress disorder, and 3.6 percent with obsessivecompulsive disorder. We also identified 1,541 GAD patients
who began new treatment during 2003. Among these
patients, the most commonly dispensed medications were
selective serotonin reuptake inhibitors, 16 percent;
benzodiazepines, 11 percent; and combination SSRIs and
benzodiazepines, 27 percent. Among the SSRIs: bupropion,
25 percent; fluvoxamine, 18 percent; sertraline, 15 percent;
mirtazapine, 15 percent; and venlafaxine, 10 percent, were the
most frequently prescribed products. On average, patients
received a course of less than five months on these SSRIs.
About 66 percent of GAD patients received at least one
specialty mental health service visit during the year. Few
patients were hospitalized during the year for any psychiatric
reasons.
Conclusions: Based on this retrospective analysis of
administrative claims data, it is apparent that the treatment
patterns for generalized anxiety disorder are varied and that
half the patients continue on medication therapy for less than
five months.
Implications for Policy, Delivery, or Practice: Generalized
anxiety disorder is prevalent, but often it is not recognized and
treated effectively in primary care practice. Treatment is
varied, and little is known about the patterns of
psychopharmacologic and other treatments in community
practice settings. Interventions are needed to assist primary
care physicians in recognizing and treating GAD and to
increase guideline consistent treatment patterns to improve
patient functioning and well being.
Primary Funding Source: Pfizer, Inc.
●A Model for Mental Health Resource Allocation and
Planning
David Hughes, MA, Stephen Leff, Ph.D., Stephen Noyes, MS,
Christopher Seaman, BS, Clifton Chow, EdM, Shekinah
Elmore, BA
Presented By: David Hughes, M.A., Project Director, HSRI,
2336 Massachusetts Avenue., Medford, MA 02155; Tel:
6178760426 ext. 2323; Email: hughes@hsri.org
Research Objective: HSRI has developed a computerimplemented simulation model using state of the art
mathematics to quantitatively estimate system needs and
system outputs, including service recipient outcomes. This
model was intended for use by system stakeholders including
consumers, policy makers, providers and administrators.
This simulator allows users to model how a current system
works, describe an ideal system and explore different
strategies for transforming a system from its current state to a
more ideal one.
Study Design: The conceptual framework for modeling
mental health systems involves several steps. First,
consumers are categorized according to their functional levels
and service needs. Next, “service package options” and their
costs and other resource requirements are identified for the
various consumer groups. Then the effects of service
packages on outcomes are estimated in terms of functional
level improvement or regression. The model can then
estimate a variety of aspects of system operations, including
service use (e.g., hospital beds, residential beds, ACT teams),
costs, outcomes, and revenue generation over any time
period.To provide inputs into the model, HSRI has developed
a Service Planning and Evaluation Survey (SPES) instrument.
This survey collects information on consumer characteristics,
services currently received, services ideally needed, and the
reasons for the discrepancies between current and ideal
services. HSRI also routinely uses consensus groups to
review the SPES data collected. The groups review the data
obtained locally and nationally and modify service
prescriptions for functional groups to bring them into
conformity with best practices.
Population Studied: The model has primarily been used for
adults with severe mental illness, but has also been used with
children with severe emotional disorders and adults with
substance use disorders. The model is flexible enough to be
adapted to any population.
Principal Findings: The model process and results will
provide the following information.•Numbers of persons
served, by functional level, time period and location (e.g. State
Hospital, Correctional system etc) •Service utilization by
service type, functional level and time period and by location
•Number of persons lost to the system •Estimate distribution
of persons by functional level based on consumer intake and
assessment files.•Positive and negative changes in client
functioning by functional level and time period •Estimate
service unit costs •Prescribe types and amounts of services for
seriously mentally ill persons at different functional levels
using data and expert judgments •Estimate annual service
system costs, taking into account estimated service needs and
unit costs and consumer outcomes.•Estimate expected
reimbursement from Medicaid or other funding sources
•Provide bed need estimates
Conclusions: Often evaluations are narrowly focused on a
single intervention or program, which is shown to be effective
taken on its own. However, such studies ignore the possible
system-wide effects of introducing a new practice. Our model
seeks to describe an entire system of services taken together
and as such provides planners with the tools to explore
system needs and the system-wide effects of specific service
changes and their possible policy implications.
Implications for Policy, Delivery, or Practice: Policy makers
can use cost and outcome projections generated by the
simulation to evaluate a wide variety of strategies for defining
the affordable need for a jail diversion program.
Primary Funding Source: No Funding Source
●National Estimates of Screening for Intimate Partner
Violence by Medical Professionals
Ruth Klap, Ph.D.
Presented By: Ruth Klap, Ph.D., Assistant Researcher, Health
Services Research Center, UCLA, 10920 Wilshire Boulevard,
Suite 300, Los Angeles, CA 90024; Tel: (310)794-3716; Fax:
(310)794-3724; Email: ruth@soc.ucla.edu
Research Objective: Practice guidelines for most medical
associations recommend screening all female patients for
Intimate Partner Violence (IPV). This study uses a nationally
representative sample to provide estimates of the proportion
of women who report ever having been screened for Intimate
Partner Violence (IPV). It assesses characteristics of women
who report that they have been screened in order determine if
minorities or individuals of lower socioeconomic status are
more likely to be screened.
Study Design: All women were asked: “Has any doctor, other
health care or mental health provider ever asked you questions
about domestic violence or family violence?” This analysis
use a multivariate logistic regression model to identify
demographic characteristics and other risk factors that are
associated with women reporting that they have ever been
screened for domestic violence.
Population Studied: A sample of 4814 women over the age of
18 who took part in the 2000-2001 Healthcare for
Communities survey, a component of the Robert Wood
Johnson Foundation’s Health Tracking Initiative, which
examines healthcare delivery for alcohol, drug abuse and
mental health conditions.
Principal Findings: Only seven percent (95% CI 5.6%-8.5%)
of the women reported that they have ever been screened for
IPV violence. None of the demographic variables (age,
marital status, race, income or education) were significantly
associated with IPV screening. The odds of a women
reporting that she was screened for IPV were higher if she
reported having one or more chronic medical conditions,
screened positive for a probable mental disorder, reported
having visited a primary care provider in the past 12 months,
or reported one or more life difficulties in the past 12 months.
Conclusions: Although evidence suggests that providers
seem to target higher risk women (those who report
psychosocial problems), the proportion of women within
these high risk subgroups who are screened remains low.
Implications for Policy, Delivery, or Practice: Even though
practice guidelines for most medical associations recommend
the screening of all women for IPV, only seven percent of the
women in this nationally representative sample reported that
they have ever been screened for IPV by a medical
professional. The evidence suggests that these practice
guidelines are not being translated into clinical practice.
Primary Funding Source: RWJF
●Do Decision Aids Promote Shared Decision-Making? A
Randomized Trial among Men Eligible for Prostate Cancer
Screening
Alex Krist, M.D., Steven Woolf, M.D., MPH, Robert Johnson,
Ph.D.
Presented By: Alex Krist, M.D., Assistant Professor, Family
Medicine, Virginia Commonwealth University, 3825 Charles
Stewart Drive, Fairfax, VA 22033; Tel: (703)391-2020; Fax:
(703)264-9861; Email: ahkrist@vcu.edu
Research Objective: Current guidelines for prostate cancer
screening urge physicians to involve patients in shared or
informed decision-making, but many physicians lack
resources to present pros and cons in a factual and balanced
format. We sought to evaluate whether pre-visit educational
decision aids facilitate shared decision-making and whether
the Internet is an effective medium to deliver this information.
Study Design: We conducted a randomized controlled
comparison of a web-based or paper-based decision aid for
prostate cancer screening versus no pre-visit education.
Participants were either emailed a link to a website or mailed a
brochure prior to their visit. Outcomes were assessed by a
post-visit patient and physician survey. The primary outcome
was the reported level of control over the prostate cancer
screening decision. Response options ranged from A to E: A
represented complete patient control without consideration of
physician input, E represented the reverse, and C represented
a purely shared decision. Locus of control was quantified as a
mean of responses, with A=2 and E=-2.
Population Studied: Over three years, we approached all men
aged 50 to 70 years with a scheduled health maintenance
examination at a family practice center in suburban
Washington, D.C.
Principal Findings: Of 1073 men scheduled for health
maintenance examinations, 497 (46%) agreed to participate
and were randomized to the control group (N = 75), brochure
group (N = 196), or the website group (N = 226). Surveys
were completed by 87% of patients and 91% of physicians. A
similar proportion of patients reviewed the material before
their visit (brochure, 88%; website, 85%). Patients exposed to
either decision aid were no more likely than controls to report
a truly shared-decision: 36% of patients in each group
reported choice C. Patients randomized to decision aids were
more likely to report greater personal control over the
decision. The mean locus of control scores for the website and
brochure groups were 0.53 and 0.55, respectively, whereas the
score for the control group was 0.25 (p=0.04). However,
decision aids did not increase concordance between actual
and patient-preferred locus of control. Patients exposed to a
decision aid demonstrated greater knowledge about prostate
cancer (correct answers on knowledge test: website, 78%;
brochure, 79%; control, 65%; p < 0.001) and were less likely to
opt for prostate specific antigen testing (receiving test:
website, 86%; brochure, 85%; control, 94%; p =0.05). In all
groups about 5 minutes was devoted to discussing prostate
cancer and patients reported low decisional conflict (1.54-1.58),
but there were no significant inter-group differences.
Conclusions: Pre-visit decision aids appeared to give patients
greater knowledge about prostate cancer and to encourage
active control over decisions but did not promote the
physician-patient shared decisions that current guidelines
advocate. Whether such a decision-making style is indeed the
ideal and how best to measure its occurrence in clinical
encounters are subjects for further research. Web-based
decision aids and mailed brochures were equally effective.
Implications for Policy, Delivery, or Practice: To the extent
that shared or informed decision-making is important to the
quality of screening decisions, clinicians will need better
strategies to promote informed choice.
Primary Funding Source: American Academy of Family
Physicians
●Hazardous Drinking Predicts Health Care Use In An
HMO
Mary Jo Larson, Ph.D., Robert LaForge, Sc.D., Annie Zhang,
BM MPH, Robert Schneider, Ph.D., Beth Schliting, MPH
Presented By: Mary Jo Larson, Ph.D., Principal Research
Scientist, Institute for Health Services Research & Policy, New
England Research Institutes, 9 Galen Street, Watertown, MA
02474; Tel: (617)923 7747 x350; Fax: (617) 826 0426; Email:
mjlarson@neri.org
Research Objective: To test the null hypothesis that there is
no association of health care utilization in a 2-year period with
baseline drinking measures among a sample of ‘at-risk’
drinkers. Measures of health care are: any hospital admission
(6%), any emergency room visit (16%), days of outpatient
care (median=8), any alcohol diagnosis care (2%), any injuryrelated care (27%), and any preventive service diagnosis or
procedure (72%).
Study Design: Secondary analysis of data from a randomized
trial. Bivariate analysis, multivariate logistic regression, and
least square regression adjusted for age, gender, body mass
index (BMI), health status, days of exercise, and smoking
status. Data consist of self-reported demographics, health
status, psychosocial status and behaviors, and HMO data files
of all health care encounters and claims for the 2-year period.
Population Studied: The sample is 1,329 at-risk, nondependent drinkers of a New England HMO in a randomized
trial of a computer-based low-intensity motivationally-matched
individualized cognitive-behavioral intervention. ‘At-risk’
drinkers had weekly intake exceeding recommended levels (14
drinks, males; 7 drinks, females), or reported heavy episodic or
“binge” drinking 1 or more times in the last month (5 or more
drinks in a row for men, or 4 or more in a row for women at
any time). Respondents with Alcohol Use Disorder
Identification Test(AUDIT) scores 17 or greater and alcohol
dependence scores greater than 20 were excluded as probable
alcohol dependence.
Principal Findings: Respondents had the following
characteristics: 51% male, mean age 42.8 years (SD 12.7), 89%
white, and 74% some employment. Self-rating of health status
was 75% excellent/very good; 3% fair or poor; mean BMI 25.8
(SD 4.5); 8% reported smoking infrequently and 14% regularly;
median days with vigorous exercise for 20 minutes was 10 in
past month. Days in past month with binge drinking: 40% no
days, 25% one day, 14% 2 days, and 21% 3 or more days.
Mean days drinking in typical week: 3.3 (SD 2.1). Mean drinks
on a typical drinking day: 2.7 (SD 1.8). Mean AUDIT score: 5.9
(SD 3.3). In multivariate analyses controlling for client
characteristics and current weekly quantity/frequency drinking,
higher AUDIT scores were associated with increased
probability of ER visits (OR=1.06, 95% CI=1.003, 1.12), care
with diagnosis of alcohol-related disorder (OR=1.13, 95%
CI=1.01-1.27), and probability of using a preventive service
(OR=1.08, 95% CI=1.03, 1.14). Drinking quantity, frequency,
and binge drinking also were independently associated with
care with an alcohol-related diagnosis.
Conclusions: An increase in hazardous alcohol consumption
patterns in a sample of generally healthy, employed, nondependent adult members of an HMO is associated with
increased odds of use of health services: 6% for ER visits, 13%
for alcohol-related care, and 8% for preventive care; but not
days of outpatient services.
Implications for Policy, Delivery, or Practice: Adult HMO
members with past year indication of hazardous drinking
patterns are using more expensive acute services in the ER as
well as more prevention-oriented services that may identify
early indications of disease.
Primary Funding Source: NIAAA
●Quality of Care for Medicaid Members with Co-morbid
Behavioral and Physical Illness
Ann Lawthers, Sc.D., Lobat Hashemi, MS, Robin Clark, Ph.D.
Presented By: Ann Lawthers, Assistant Professor, Center for
Health Policy and Research, University of Massachusetts
Medical School, 222 Maple Avenue, Shrewsbury, MA 01545;
Tel: (508)856-1531; Email: ann.lawthers@umassmed.edu
Research Objective: To assess the quality of treatment,
monitoring and preventive care for chronic physical illness
among Medicaid members with mental health or substance
abuse disorders enrolled in a primary care case management
program.
Study Design: Using Medicaid claims data, members were
grouped into three behavioral health (BH) categories based on
diagnoses: severe mental illness (schizophrenia, other
psychotic disorders, bipolar disorder or major depression),
other behavioral health disorders or no behavioral health
diagnoses. Drug or alcohol disorders were identified
separately within the first two groups. Individuals with
asthma, chronic obstructive pulmonary disease (COPD),
hypertension, ischemic heart disease or diabetes mellitus were
identified within each of the three BH categories. Individuals
could be assigned to multiple physical disease groups but to
only one behavioral health category.
Quality of care indicators for treatment, monitoring or
prevention were identified for each physical disease group
based on HEDIS measures and other evidence-based
measurement initiatives. Medicaid claims analyses
determined whether each indicator was met and summed
across all indicators to create a quality score for each
individual. Scores were then averaged to produce summary
quality of care measures each physical condition.
Population Studied: Study population included 120,933
Medicaid members between the ages of 18 and 64 who were
enrolled in Massachusetts’ Primary Care Clinician (PCC) Plan
for >320 days in fiscal year 2003 (July, 2002 through June,
2003.) Approximately one-fifth (21.8%) had a severe mental
disorder (SMI), one fifth (20.3%) had another type of
behavioral health diagnosis (Other BH). The remainder had
no claims with a mental health or substance abuse diagnosis
(Non-BH). One quarter of the population had at least one of
the five identified physical conditions.
Principal Findings: Rates of asthma, diabetes and
hypertension were highest in the SMI group. The “Other BH”
group had slightly higher rates of heart disease and COPD.
Quality of care scores ranged from 59% for heart disease to
66% for asthma. Quality differences across the three
behavioral health groups were small, ranging from one
percentage point for hypertension to four points for diabetes.
Contrary to expectations, individuals with SMI had the highest
quality scores for each physical condition. Members of the
Other-BH group consistently had the lowest scores. Drug and
alcohol disorders were strongly associated with lower quality
of care. Members with a substance abuse disorder had scores
from six to eight percentage points lower than others. Use of
preventive care by those without a chronic physical condition
suffered the most, with substance abusers averaging 12%
lower scores than others.
Conclusions: Substance abuse is consistently associated with
lower quality of care for physical illness. Within this particular
managed care program, individuals with SMI received physical
health care similar to, or better than, that provided to other
groups.
Implications for Policy, Delivery, or Practice: These data
suggest that interventions targeting individuals with alcohol or
drug abuse diagnoses may improve the quality of physical
health care.
Primary Funding Source: Other
●Overview of the PRISM-E Study: Methodology and
Access to Care
Sue Levkoff, Sc.D., Eugenie Coakley, MPH, Steve Bartels, MD,
Hongtu Chen, Ph.D., Susan Grantham, Ph.D., Dean Krahn,
MD
Presented By: Sue Levkoff, Sc.D., Assoc. Professor,
Psychiatry, Brigham & Women's Hospital, Harvard Medical
School, 1249 Boylston Street, 3rd Floor, Boston, MA 02115;
Tel: (617) 525-6122; Email: sue_levkoff@hms.harvard.edu
Research Objective: The PRISM-E Study is a multisite
randomized trial comparing two types of care models for
delivery of mental health services to elderly people through
primary care, i.e., the integrated care (IC) model and an
enhanced specialty referral model (ESR). The paper will
describe the PRISM-E research methodology and findings with
regard to access to care.
Study Design: Older adults aged 65 and above were screened
at primary care clinics from 10 study sites throughout the
U.S.A. Those who met diagnostic criteria for depression,
anxiety, and/or at-risk alcohol consumption were randomly
assigned to either IC or ESR models.
Population Studied: Older adult (over 65 years old) users of
primary care services at eleven study sites throughout the
country. Study settings included community health centers,
VA facilities, and other community primary care clinics.
Over 25,000 older adults were screened for mental health and
alcohol drinking problems in primary care settings. More than
2,200 elderly primary care patients with depression, anxiety,
and at-risk drinking participated in this study.
Principal Findings: Among those randomized, seventy-one
percent of patients engaged in treatment (defined as at least
one visit) in the integrated model compared with 49% in the
enhanced referral model. Integrated care was associated with
more mental health and substance abuse visits per patient
(mean=3.04) relative to enhanced referral (mean=1.91).
Overall, greater engagement was predicted by integrated care
and higher mental distress. For depression, greater
engagement was predicted by integrated care and more severe
depression. For at-risk alcohol users, greater engagement was
predicted by integrated care and more sever problem drinking.
For all conditions, greater engagement was associated with
closer proximity of mental health/substance abuse services to
primary care.
Conclusions: Older adult patients are more likely to accept
mental health treatment within a primary care setting than in
mental health/substance abuse clinics.
Implications for Policy, Delivery, or Practice: As older
adults under-use the mental health system, this study
provides empirical support for policy reform aimed at
improving access to coordinated behavioral health services by
integrating the mental health and primary care sectors.
Primary Funding Source: SAMHSA
●Knowledge of Prostate Cancer Screening and Treatment
Lauren McCormack, Ph.D., MSPH, Carla Bann, Ph.D., Pam
Williams-Piehota, Ph.D., David Driscoll, Ph.D., May Kuo, Ph.D.
Presented By: Lauren McCormack, Ph.D., MSPH, Program
Director, Health Communication, RTI International, 3040
Cornwallis Road, RTP, NC 27709; Tel: (919) 541-6277; Fax:
(919) 990-8454; Email: Lmac@rti.org
Research Objective: To evaluate how knowledgeable men are
about prostate cancer screening and treatment and to
measure the impact of a community-based intervention to
increase knowledge.
Study Design: We developed a set of interventions to provide
men with the information, skills, and reinforcement needed to
make informed decisions about the prostate-specific antigen
(PSA) test and to promote informed decision making between
them and their clinicians. The interventions include
brochures, videos, shirt pocket cards with frequently asked
questions, websites, and oral presentations with mutually
reinforcing messages about prostate cancer screening. We
implemented the interventions as part of a series of health
education sessions held at community-based organizations
including men’s groups, clubs, fraternal and faith-based
organizations. The sessions followed a standard protocol of a
physician delivering the oral presentation, viewing of the 20minute video followed by a question and answer period, and
dissemination of the print materials. We administered preand post-intervention surveys and conducted in-depth
individual interviews with a small subset of participants.
Population Studied: Men between the ages of 40 and 80
residing in three homogenous North Carolina communities
(two intervention and one control) that were identified
through an iterative sampling procedure and assessment of
social capitol.
Principal Findings: Both measures of knowledge about
prostate cancer -- a 10-item knowledge quiz at baseline and a
5-item sub-scale immediately after exposure to the
intervention -- demonstrated good psychometric properties.
Men who scored higher on the knowledge quiz had greater
educational achievement and rated their own knowledge as
higher. Based on preliminary analysis of the data, we found
that knowledge about prostate cancer is quite low in some
areas, including awareness of possible reasons for a high PSA
value other than the presence of cancer (27 percent correct)
and familiarity with the side effects of common treatments (52
percent correct). Following the intervention sessions,
knowledge about prostate cancer screening and treatment
increased significantly on the 5-item sub-scale reflecting key
issues addressed in the sessions. The magnitiude of
knowledge improvement ranged from five percent on a
question about whether most prostate cancer are slowgrowing or fast-growing to over 50 percent for a question
about the proportion of men who experience permanent side
effects from treatment.
Conclusions: Carefully designed interventions aimed at
educating men about prostate cancer and delivered through
community-based mechanisms have the potential to increase
knowledge.
Implications for Policy, Delivery, or Practice: There is
uncertainty regarding whether the benefits of PSA screening
outweigh the harms. Given the complexity of the issue and
the importance to educate people about the uncertainty,
interventions to increase knowledge that can be used in
community settings are needed.
Primary Funding Source: CDC
●The Changing Demand for Mental Health Treatment,
1996-2002
Chad Meyerhoefer, Ph.D., Samuel Zuvekas, Ph.D.
Presented By: Chad Meyerhoefer, Ph.D., Economist, Center
for Financing, Access and Cost Trends, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: (301)427-1664; Fax: (301)427-1276; Email:
cmeyerhoe@ahrq.gov
Research Objective: The expanded availability of
pharmacological treatment alternatives and rapid rise of
managed behavioral health care organizations during the
1990s have significantly influenced utilization patterns of
mental health services in the United States. While inpatient
costs have been reduced through managed care and more
effective outpatient treatment regiments, the use of
pharmacotherapy by both specialty mental health providers
and primary care physicians has increased substantially. The
associated rise in drug expenditures has lead to renewed
concerns over cost escalation by both public and private
payers. We seek to understand the underlying behavioral and
economic dynamics driving changing patterns of utilization,
and in particular, the rising demand for pharmacotherapy and
the substitution between this treatment approach and
behavioral therapy.
Study Design: We derive a mental health care demand model
that incorporates all the relevant costs influencing
consumption decisions, including out-of-pocket payments (copayments) for ambulatory services, out-of-pocket prescription
drug charges, insurance premiums, and the individual’s time
cost of treatment. The model is then used to estimate the
joint demand for pharmacotherapy, behavioral therapy, and
non-mental health treatment. The empirical approach builds
on previous work by Frieman and Zuvekas (Health
Economics, 1999), Meyerhoefer, Sahn, and Younger (CFNPP
Working Paper No.125, 2004), and Meyerhoefer, Ranney, and
Sahn (AJAE, forthcoming) to account for both monetary and
opportunity costs of seeking care, and control for the
endogeneity of model regressors by exploiting the longitudinal
aspect of the Medical Expenditure Panel Survey (MEPS).
Comprehensive treatment of monetary and opportunity costs
is particularly important in the mental health context since
many individuals face substantial out-of-pocket costs for care,
and there exists a large differential in the time cost of
treatment between behavioral and pharmacotherapy.
Population Studied: This study uses all age cohorts of the
1996-2002 MEPS, a nationally representative survey of the
civilian, non-institutionalized U.S. population.
Principal Findings: Descriptive results demonstrate
substantial increases in both the level of expenditures on
pharmacotherapy and their share relative to behavioral
therapy. Considerable sample variation in out-of-pocket costs
is also found, with the uninsured facing mental health
prescription drug prices that are more than twice that paid by
the Medicare, Medicaid, and privately insured populations.
Preliminary findings from the multivariate analyses suggest
that out-of-pocket payments have a significant impact on
demand patterns and that consumers view behavioral and
pharmacotherapy as complements.
Conclusions: Current cost-sharing arrangements for mental
health services should be re-examined to determine whether
they lead to the best combination of behavioral and drug
therapies given the sensitivity of consumer demand to both
out-of-pocket costs and the time costs of treatment.
Implications for Policy, Delivery, or Practice: Price (or outpocket cost) elasticity estimates from the model will provide
policymakers and health plan managers important indications
of how consumer responsiveness to mental health treatment
has changed since the RAND Health Insurance Experiment.
These elasticities can be used by the latter to forecast benefit
costs and by the former to determine whether current cost
sharing arrangements place financial burdens on consumers
that reduce the quality of mental health care by limiting access
to needed services.
Primary Funding Source: AHRQ
●Are Public/Private Partnerships Delivering Better Public
Mental Health Services for the Safety Net Population?
Sarita Mohanty, M.D., MPH, Allison L. Diamant, M.D., MSHS,
Isabel Lagomasino, M.D., MSHS, Steven Asch, M.D., MPH
Presented By: Sarita Mohanty, M.D., MPH, Assistant
Professor of Medicine, Medicine, University of Southern
California, 2020 Zonal Avenue, IRD 627, Los Angeles, CA
90033; Tel: (323) 226-5579; Fax: (323) 226-2718; Email:
samohant@usc.edu
Research Objective: Low-income patients may receive fewer
depression care services due to limitations of available
primary care services. We compared depression care delivered
by county-contracted public private partnership (P/PP)
primary care clinics and those owned and operated by the Los
Angeles County Department of Health Services (LAC-DHS).
The P/PPs are partnerships between the LAC-DHS and
private, community-based providers that provide quality health
services to low income and uninsured communities with
limited access to primary care. The county-contracted clinics
(Health Centers (HCs), Hospital Outpatient Clinics (HOCs)
and Comprehensive Health Centers (CHCs)) vary with regards
to volume and access to services.
Study Design: Cross-sectional study of patients who
completed the Patient Assessment Survey II (PAS II) between
February-July 2002. A person was considered depressed if
they reported ever being told that they had depression and
also screened positive on a 3-item depression screener. Main
outcome measures included: 1) primary care provider´s
suggestion of MH counseling; 2) patient attended at least one
counseling session; 3) patient receiving a prescription
medication for MH. Since either treatment modality
(counseling or antidepressant medica-tion) is accepted as
first-line treatment for depression, we also analyzed patients
who were either suggested counseling or received medication
as an indicator of the quality of care delivered by both the
provider and facility. We also looked at those who attended at
least one counseling session or received medication for
depression treatment as an indicator of quality of care actually
received. Using multivariable logistic regression adjusting for
sociodemographic characteristics, we compared the receipt of
these depression services by facility type.
Population Studied: 165 depressed patients in the LAC-DHS
primary care clinic network who made at least one visit to a
doctor in the past year.
Principal Findings: In bivariate analysis, P/PPs and CHCs
had higher rates in providing depression care compared to
other county-owned facilities. After multivariate adjustment,
county-owned HCs had the lowest odds of suggesting a
counseling session (Adjusted OR 0.32, 95% CI 0.10, 1.00 vs.
CHCs), of having patients who had a counseling session
(AOR 0.22, 95% CI 0.07, 0.76 vs P/PPs), and prescribing a
medication (AOR 0.17, 95% CI 0.05, 0.54 vs. P/PPs) for
depression. Patients in P/PPs and CHCs were more likely to
either be suggested counseling or receive a medicaton
compared to HCs and HOCs. However, P/PPs patients were
more likely to actually receive a counseling session or be
administered medications for depression compared to the
other County-owned facilities (AOR: HOC 0.1, 95% C.I. 0.3,
0.8; HC 0.1, 95% CI 0.02, 0.3; CHC 0.2, 95% C.I. 0.04, 0.98.
All AOR compared to referent P/PP).
Conclusions: P/PPs provide better overall depression care
compared to the other facility types given the difficult social
circumstances of public health delivery systems. The P/PP
model appears to be a more effective model of primary care
for depression.
Implications for Policy, Delivery, or Practice: Policy makers
should take the variation of facility type into account when
working to improve depression services and determining
allocation of resources for the two different delivery models.
Primary Funding Source: Los Angeles County Department of
Health Services
●Negative Coping, Lifetime Traumatic Events, and Risk
Taking Behavior are Associated with Poor Antiretroviral
Adherence in a Cohort of HIV-infected Patients in the
Rural Southeast U.S.
Michael Mugavero, M.D., Jan Ostermann, Ph.D., Jane
Leserman, Ph.D., Kathyrn Whetten, Phd, MPH, Marvin Swartz,
M.D., Nathan Thielman, M.D., MPH
Presented By: Michael Mugavero, M.D., AHRQ & Infectious
Diseases Fellow, Medicine, Duke University, Division of
Infectious Diseases, DUMC, Box 3824, Durham, NC 27710;
Tel: (919) 684-2660; Fax: (919) 684-8902; Email:
michael.mugavero@duke.edu
Research Objective: Several observational studies have
evaluated factors predictive of antiretroviral (ARV) adherence
in HIV-infected patients. These analyses have tended to study
patients from single urban medical centers and to focus upon
demographic and clinical variables. To date few investigations
have evaluated the relationship of coping on ARV adherence.
To our knowledge no studies have evaluated the relationship
of lifetime traumatic events (such as sexual abuse, physical
abuse, parental violence, neglect) on ARV adherence. Our
objective is to determine the association of these factors with
ARV adherence in a population of HIV-infected patients in the
rural southeast.
Study Design: We conducted a cross-sectional analysis of the
Coping with HIV/AIDS in the Rural Southeast (CHASE) Study
cohort. Interview data at enrollment included detailed
assessments of adherence, mental health, coping, stressors,
and history of lifetime traumatic events in study participants.
This study evaluates factors associated with adherence among
CHASE subjects on ARV therapy at the time of enrollment.
Self-reported adherence at 1 week was used to assign subjects
to the adherent and non-adherent groups. Two sample t-tests
were used to compare clinical, demographic, and psychosocial
predictor variables in the 2 study groups. A logistic regression
model was estimated to evaluate the predictors of nonadherence in a multivariate model. Statistical significance is
defined as p<0.05.
Population Studied: The CHASE Study is a prospective
cohort study of 611 consecutively sampled HIV-infected
patients from infectious diseases clinics in 5 southern states:
AL, GA, LA, NC, and SC.
Principal Findings: Among the 474 subjects in the CHASE
cohort who were taking antiretroviral therapy at enrollment,
24% of subjects (n=112, age 40.3, female 30%, minority 61%)
reported non-adherence at 1 week, and 76% of subjects
(n=362, age 40.7, female 29%, minority 69%) reported
complete adherence. In univariate analysis, negative coping
(denial, self blame, behavioral disengagement, substance use)
(p<0.001), number of lifetime traumatic events (p=0.003),
alcohol use (p<0.001), illicit drug use (p<0.001), and risk
taking behavior (p=0.001) were associated with nonadherence. Positive coping (active, emotional support,
acceptance, positive reframing, religious) was associated with
complete adherence (p=0.012). Sociodemographic variables
including age, race/ethnicity, gender, and rurality were not
associated with ARV adherence. Multivariate analysis found
that negative coping (OR=1.55, 95%CI=1.02,2.35, p=0.04),
number of lifetime traumatic events (OR=1.11, 95%CI=1.0,1.23,
p=0.04), and risk taking behavior (OR=2.01, 95%CI=1.19,3.4,
p<0.01) were independently associated with self-reported nonadherence. Positive coping was predictive of complete
adherence (OR=1.51, 95%CI=1.1,2.27, p=0.03) after controlling
for other study variables.
Conclusions: Negative coping, number of lifetime traumatic
events, and risk taking behavior are independently associated
with poor ARV adherence in a cohort of HIV-infected patients
in the rural southeast. Positive coping is associated with
complete ARV adherence.
Implications for Policy, Delivery, or Practice: Given the high
prevalence of negative coping and lifetime traumatic events
among HIV-infected patients, our study has important
implications. Interventions successful in improving coping,
and addressing lifetime traumatic events, and risk taking
behaviors may improve ARV adherence in HIV-infected
patients. Since ARV adherence is a critical determinant of
clinical outcomes in HIV-infected patients, such interventions
are warranted.
Primary Funding Source: National Institute of Mental Health
●Effect of Depression- Targeted Telephon –Based
Outreach on Medically Ill Individuals
Michael Ong, M.D., Ph.D., Mitchell Feldman, M.D. MPhil,
Elizabeth Ciemins, Ph.D., Francisca Azocar, Ph.D.
Presented By: Michael Ong, M.D., Ph.D., VA Ambulatory Care
Fellow, Medicine, Stanford University, 117 Encina Commons,
Stanford, CA 94305; Tel: (650)723-1503; Fax: (650)723-1919;
Email: mikeong@stanford.edu
Research Objective: Medically ill patients often have comorbid mental illness, particularly depression, but are less
likely to use mental health services compared to other
patients. Early detection and treatment of depression may
minimize the health and economic costs of depression.
Telephone-based outreach services to medically ill individuals
not previously known to have mental illness could improve
detection and treatment of depression in an outpatient
setting.
Study Design: A pilot study of telephone-based outreach
services was evaluated using a matched cohort of 41 enrollees
and 48 controls. Both groups were surveyed one year after
enrollees received telephone-based outreach services, and had
their health care costs and utilization evaluated both pre- and
post-intervention.
Population Studied: Individuals were enrolled if they incurred
high medical utilization in the past year or had a recent
hospitalization. Depression status was unknown prior to
enrollment. Matching was based on age, sex, medical
diagnosis and prior year medical claim costs.
Principal Findings: Enrollees were more likely to have poor
self-reported health (19.5% vs. 4.2%, p<0.05) and higher
PHQ-9 scores than controls (8.1 vs. 4.0, p<0.01). Among the
18 enrollees and 25 controls who were currently employed,
enrollees worked more hours per week (39.7 vs. 32.1, p<0.10)
and were more likely to work full-time (77.8% vs. 48.0%,
p<0.10) compared to controls. Controls had no behavioral
health utilization, but enrollees had more behavioral health
utilization (2.1 claims vs. 8.0 claims, p<0.05) and higher costs
($16.73 per month vs. $39.20 per month, p<0.05) after the
intervention. Both enrollees (17.3 to 26.4, p<0.05) and
controls (6.3 to 10.6, p<0.05) had increased medical
utilization after the intervention. Total costs did not
significantly decline for enrollees ($1129 per month to $1028
per month) but did for controls ($291 per month to $254 per
month, p<0.10) Regression analyses showed no significant
relationship between the intervention and total costs, but
showed that the intervention added 9.16 hours to the total
hours worked per week (p<0.05).
Conclusions: Telephone-based outreach services appear to
enhance the work productivity of those enrollees who
continued to work one year after receiving outreach.
Telephone-based outreach services do significantly increase
behavioral claim costs. However, this increase is small in
comparison to overall medical costs, which also are not
significantly increased after the intervention.
Implications for Policy, Delivery, or Practice: As workrelated costs comprise over half of the associated costs of
depression, depression-targeted telephone-based outreach
services may be a useful adjunct in reducing the burden of
depression.
Primary Funding Source: RWJF
●Determinant Factors of Exercise Activities in
Metropolitan Immigrant Communities
Chang Park, Ph.D., Beverly McElmurry, Ed.D., FAAN, Linda L.
McCreary, Ph.D., Lucy Gormez,
●Trends in Mainecare Behavioral Health Care
Expenditures: 1996 to 2002
Susan Payne, Ph.D., MPH, Stuart Bratesman, MPP, David
Lambert, Ph.D., Marta M. Frank, MSN, MPA
Presented By: Chang Park, Ph.D., Research Specialist, College
of Nursing, University of Illinois at Chicago, 845 South
Damen, Chicago, IL 60612; Tel: (312)996-7058; Fax: (312)9968945; Email: parkcg@uic.edu
Research Objective: Promoting exercise has been considered
a critical means to reduce the high prevalence of obesity and
chronic disease like diabetes and hypertension and
cardiovascular disease.
Identification of factors related to exercise related activities is a
critical step to design and implementation of effective
community based exercise programs.
This study examined the contributing factors (personal and
ecological factors) of diverse types of exercise with controlling
neighborhood effects and similarity among activities.
Study Design: Data collected from a community survey in a
immigrant community in Chicago to identify the exercise
needs of residents in the community to develop a community
based exercise program. This study implemented a
multivariate probit model that can control unidentified
personal and ecological factors and similarities among
exercises. Neighborhood effects were controlled using census
block level cluster control. Accessibility to community
resources was measured by estimating average distance
between an individual’s house and neighboring park facilities
with GIS information provided by the survey. The multivariate
probit regression was model was estimated by the method of
simulated maximum likelihood (SML) using the GewekeHajivassiliou-Keane (GHK) simulator.
Population Studied: Hispanic dominant immigrant
communities in Midwestern metropolitian area.
Principal Findings: Community factors like community
safety, accessibility to facilities are significant only in
explaining running, walking.
For personal factors, age was significant for running, jogging,
biking and swimming. However, gender was significant for
running, biking and swimming. Employment status only
explained biking and swimming.
Conclusions: These study results indicated the different level
of significance and extent of diverse ecological and personal
factors on exercise activities.
Implications for Policy, Delivery, or Practice: These findings
can be utilized for designing cost-effective exercise activities
for immigrant communities.
Primary Funding Source: University of Illinois at Chicago &
RWJF
Presented By: Susan Payne, Ph.D., MPH, Professor, Muskie
School of Public Service, University of Southern Maine, P.O.
Box 9300, Portland, ME 04104-9300; Tel: (207) 780-5104; Fax:
(207) 780-4953; Email: spayne@usm.maine.edu
Research Objective: Identify trends in Maine's MaineCare
(Medicaid) expenditures for behavioral health services
between state fiscal years (SFYs) 1996 and 2002; compare
MaineCare spending on service users with and without
behavioral conditions in SFY 2002; and identify reasons for
the cost increases.
Study Design: We analyzed MaineCare claims and eligibility
data for SFYs 1996, 1999, and 2002. MaineCare members
were assigned to the behavioral conditions population if they
had a claim with a behavioral-related diagnosis or for a
behavioral-related service. Behavioral conditions included
mental illness and substance abuse-related mental illness.
Members in the study population were assigned to one-ormore of ten broad behavioral diagnostic categories based on
AHRQ's Clinical Classification Software (CCS) system.
Claims expenditures were classified as behavioral, long term
care, or medical/other based upon claims categories.
Pharmaceutical claims were classified as behavioral or
medical/other based upon the primary therapeutic use for the
drug.
Population Studied: All MaineCare members who had at
least one claim for a non-pharmacy service during any one of
the three study years.
Principal Findings: Between 1996 and 2002, MaineCare
expenditures for persons with behavioral health conditions
rose by 117.5% from 46,183 to 81,377, or four times more than
for MaineCare members without a behavioral condition.
By 2002, 38.3% of the MaineCare members studied had at
least one behavioral condition; as a group, they accounted for
56.6% of all MaineCare expenditures.
The biggest driver of increases in total costs was a 76.2% rise
in the number of members with a behavioral health condition.
The number of children increased even more – by 102.4%.
The three CCS behavioral categories with the fastest growing
number of persons were Substance Abuse-Related Mental
Disorders (up by 165%), Other Mental Conditions (106%),
and Affective Disorders (103%). The slowest growing groups
included Alcohol-Related Mental Disorders, Senility and
Organic Mental Disorders, and Schizophrenia and Other
Psychoses. Average per member per month (PMPM) total
costs (including all behavioral and non-behavioral MaineCare
expenditures) for members with a behavioral diagnosis
increased 17.1% over the study period, compared to 9.1% for
other members. The diagnosis groups with the highest
average PMPM total costs in 2002 were Senility and Organic
Mental Disorders ($2,854), Schizophrenia and Other
Psychoses ($2,695), and pre-adult disorders ($1,974).
Average PMPM MaineCare expenditures increased as the
number of behavioral diagnoses increased. In 2002, 42.2% of
the study population had behavioral diagnoses in two-or-more
Clinical Classification Software behavioral categories, up from
36.5% in 1996. While members with a diagnosis in only one
category averaged $826 PMPM in total MaineCare
expenditures, members with diagnoses in five-or-more
averaged $2,849 PMPM.
Conclusions: By every measure examined, use and costs
increased dramatically for members with behavioral
conditions, and by more than for non-behavioral members.
The proportion of MaineCare members with a behavioral
condition rose rapidly in recent years, due in part to expanded
coverage of children and adults, use of evidence-based
practice, greater use of substance abuse treatment, and
shifting funding from general funds to Medicaid.
Implications for Policy, Delivery, or Practice: MaineCare will
not be able to control overall expenditures without paying
close attention to the provision of behavioral health care
services.
Primary Funding Source: State of Maine: Bureau of Medical
Services
geographic locations (R2 = 0.279). Adherence to the
guidelines was not influenced by whether the patient was
referred (R2 = 0.456).
Conclusions: Physician’s specialty, geographic location, and
practice setting influences adherence to JNC-7 guidelines.
Cardiologists and Family Practice Physicians appear to adhere
to the guidelines better.
Implications for Policy, Delivery, or Practice: Drug therapy
constitutes a significant portion of the cost of hypertension
therapy. Thiazide type drug prescribing for hypertension helps
control/reduce the cost of hypertension therapy. Further
research, reviewing the causes of the significant differences
seen in this study would help manage hypertension better.
Thiazide diuretic drug therapy for hypertension should be
addressed more explicitly in physicians practice.
Primary Funding Source: Shenandoah University
●Physicians Prescribing Pattern of Thiazide Diuretics for
Hypertensive Patients
Ateequr Rahman, MBA, Ph.D.
●A Linear Approximation to Item Response Theory
Scoring of a Mental Health Outcome Instrument
Gayatri Ranganathan, Ph.D., David Esch, Ph.D
Presented By: Ateequr Rahman, MBA, Ph.D., Assistant
Professor, Pharmacy, Shenandoah University, College of
pharmacy, Winchester, VA 22601; Tel: (540)678-4365; Fax:
(540)665-1283; Email: arahman@su.edu
Research Objective: Hypertension affects approximately 50
million individuals in the United States and approximately 1
billion individuals worldwide. In US alone, it costs $12 billion
annually for the management of hypertension. Drug therapy is
a major cost associated with the management of
hypertension. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC-7) has provided new
guidelines for hypertension prevention and management. One
of their guidelines is that thiazide-type diuretics should be
used in drug treatment of most patients with hypertension
either alone or combined with drugs from other classes.
Diuretics enhance the antihypertensive efficacy of the
multidrug regimens, can control blood pressure effectively,
and are more affordable than other antihypertensive agents.
Despite these recommendations, diuretics remain underused.
This study examined the Physicians’ prescribing pattern of
thiazide diuretics for hypertensive patients and compared
them with guidelines issued by the Joint National committee
(JNC-7) for adherence.
Study Design: Adherence to guidelines was estimated across
several physician factors. Physician factors such as specialty,
practice settings, geographic location and patient referral
status were studied for adherence to the JNC-7 guidelines.
Population Studied: Data from the National Ambulatory
Medical Care Survey (NAMCS) 2003 was utilized. Patients
with principal diagnosis of Hypertension (ICD-9 code 401404) were analyzed using multiple linear and binomial logit
regression models. Adherence to guidelines was defined as
those hypertensive patient profiles, which included a thiazide
type diuretic.
Principal Findings: Family practice physicians and
cardiologists adhered to the guidelines better than the
internists and other physicians. (R2 = 0.434). Physicians in
individual practice adhered to the guidelines better compared
to the group practices (R2 = 0.329). Physician in the Midwest
adhered to the guidelines better compared to the other
Presented By: Gayatri Ranganathan, Ph.D., Associate
Professor, Health Research Scientist, Center for Health
Quality, Outcomes & Economics Research, Edith Nourse
Rogers Memorial Veterans Hospital, 200 Springs Road (152),
Bedford, MA 01730; Tel: (781)687-2858; Fax: (781)687-3106;
Email: seisen@bu.edu
Research Objective: The objective of this study was to
develop a linear approximation to IRT scores that would be
practical for use by clinical programs in outcomes monitoring
efforts. Item Response Theory (IRT) is currently considered
the state-of-the-art method for developing health assessment
measures. In a recently completed study, we used IRT
modeling to create a more efficient and parsimonious mental
health outcome instrument assessing six symptom and
functioning domains: depression/functioning, interpersonal
relationships, self-harm, emotional lability, psychosis and
substance abuse. However, IRT scores are not practical for
most mental health programs to compute. They require
specialized software and a high level of statistical expertise.
Scoring new data with IRT requires either performing
numerical quadratures of the likelihood posterior distribution
or keeping a table of all possible response patterns. In
addition, because IRT modeling generates standardized
scores, results cannot be compared across programs.
Consequently, it is important to develop methods of scoring
instruments that incorporate state of the art methods but that
are practical for implementation in clinical programs.
Study Design: Qualitative and quantitative methods reported
in earlier work were used to revise, field test and validate the
mental health assessment instrument (Behavior and
Symptom Identification Scale, BASIS-32). The instrument was
administered to psychiatric inpatients at admission and 24
hours before discharge, and to psychiatric outpatients at
intake and 30-60 days later. A scoring algorithm was
developed for the instrument using factor analytic and Item
Response Theory modeling. Mean domain scores and an
overall summary score were used as independent variables to
derive weights to be used in a linear approximation of the IRT
scores. Weights were calculated using an ordinary least
squares (OLS) regression of the IRT-derived domain and
overall summary scores (the dependent variables). The
coefficients obtained are then the weights used in the linear
approximation. Weighted scores were computed by
multiplying item ratings by weights for each of the six
subscales assessed by the instrument. Separate weights were
computed for the overall summary score. Weighted scores
were then correlated with IRT scores to determine how much
of the variance in IRT scores was captured by the linear
approximation.
Population Studied: The population studied consisted of
5,878 individuals receiving inpatient (n=2,656) or outpatient
(n=3,222) mental health and/or substance abuse services at
one of 28 programs throughout the U.S.
Principal Findings: Correlations between the weighted scores
and the IRT scores ranged from .97 to .99 for the six domains
and for the overall summary score, suggesting excellent linear
approximations.
Conclusions: The weighted linear scores captured most of
the variability in the IRT scores. Some small non-linearities
occurred, which probably matter very little in terms of use of
the instrument.
Implications for Policy, Delivery, or Practice: Reliable, valid
and sensitive measures are needed to determine outcomes of
behavioral health treatment at all levels of care. This linear
approximation methodology provides a straightforward and
effective way for clinical programs to utilize the highly
sophisticated health status measurement methods that are
currently available.
Primary Funding Source: NIMH
●Development of a Diagnosis-based Risk-Adjustment
Measure for Mental Health Care
Amy Rosen, Ph.D., Kevin Sloan, M.D., Maria Montez, MS,
Cindy Christiansen, Ph.D., Susan Eisen, Ph.D., Avron Spiro,
Ph.D.
Presented By: Amy Rosen, Ph.D., Director of Risk
Assessment and Patient Safety, Health Services, Center for
Health Quality, Outcomes and Economic Research, 200
Springs Road (152), Bedford, MA 02478; Tel: (781) 687-2960;
Fax: (781) 687-3106; Email: akrosen@bu.edu
Research Objective: Despite the difficulties in applying
existing risk-adjustment measures to mental health
populations, the need for adequate risk-adjustment
methodologies continues to increase with ongoing pressures
to constrain costs and allocate resources equitably across key
population subgroups. The VA operates the largest mental
health service delivery system in the nation, providing
comprehensive and specialty mental health and substance
abuse (MH/SA) services to over 650,000 veterans annually.
The prevalence of mental disorder is generally higher in the VA
than in other healthcare systems, with approximately 29% of
patients having at least one MH/SA disorder. Thus, the VA is
an ideal healthcare system in which to explore the
development of a risk-adjustment methodology specific to
mental health care. In this study, we develop a psychiatric riskadjustment measure (the “PRAM”) using ICD-9-CM diagnosis
codes to classify patients into specific MH/SA categories. We
examine the face validity of our classification system, the
reliability of diagnostic classification, and compare the
performance of the PRAM with other leading risk-adjustment
measures, such as the Diagnostic Cost Groups (DCGs).
Study Design: We selected 914,225 patients from VA
administrative files who had MH/SA diagnoses (identified by
ICD-9-CM codes 290.00-312.99, 316.00-316.99) and who
utilized VA inpatient and outpatient healthcare services in
Fiscal Year (FY) 1999 (10/1/98-9/30/99). Face validity of the
PRAM was evaluated through clinical review and empirical
analyses (e.g., distribution of patients into diagnostic
categories). To test reliability, diagnostic classifications were
developed on a 60% sample (n=548,535) and validated on a
40% sample (n=365,690). We ran concurrent and prospective
ordinary least squares regression models to predict MH/SA
costs and number of outpatient encounters.
Population Studied: Patients with MH/SA disorders who had
inpatient and/or outpatient healthcare utilization in FY’99.
Principal Findings: We classified all relevant ICD-9-CM
MH/SA diagnoses into 46 mutually exclusive diagnostic
categories using clinical and empirical criteria. We imposed
four hierarchies (drug/alcohol, psychoses, mood disorders,
and anxiety disorders) in order to further define clinically
homogeneous groups. The average number of categories per
patient was 2.71. The most prevalent diagnostic categories
included depression (24.8%), nicotine dependence (24.0%),
post-traumatic stress disorder (18.4%), and alcohol
dependence (16.2%). Concurrent and prospective R-squares
for MH/SA costs were 0.113 and 0.064, respectively, and
0.246 and 0.066 for outpatient encounters, respectively. Rsquares were comparable for each of the development and
validation samples. R-squares for the PRAM were somewhat
higher than those for DCGs (e.g., concurrent R-squares for
MH/SA costs were 0.113 and 0.095, respectively).
Conclusions: Our findings suggest that the PRAM has good
face validity and reliability. Compared to other risk-adjustment
systems developed for general populations, such as the
DCGs, our risk-adjustment measure performed slightly better
in predicting MH/SA costs.
Implications for Policy, Delivery, or Practice: The PRAM
appears to be a reasonable alternative method for describing
the disease burden of the VA’s MH/SA population.
Developing a measure specific to the VA permits a more
accurate assessment of the mental health burden of this
population. Further research needs to determine its
applicability to other health care systems.
Primary Funding Source: VA
●Checking Smoking Status as a Vital Sign: A Randomized
Trial of its Effect on Counseling
Stephen F. Rothemich, M.D., MS, Steven H. Woolf, M.D.,
MPH, Robert E. Johnson, Ph.D., Amy E. Burgett, RN, Sharon
K. Flores, MS, David W. Marsland, M.D.
Presented By: Stephen F. Rothemich, M.D., MS, Associate
Professor, Family Medicine, Virginia Commonwealth
University, 1200 East Broad Street, Richmond, VA 23298; Tel:
(804)828-9625; Fax: (804)827-0227; Email:
srothemich@vcu.edu
Research Objective: To evaluate the effectiveness of checking
smoking status as a vital sign in increasing cessation
counseling rates in primary care practices. The primary
hypothesis was that intervention practices would more
frequently provide cessation counseling (simple advice and/or
discussion of how to quit) to adult smokers. Our secondary
hypotheses were that the subcategories of counseling (simple
advice and discussion of how to quit) would each be delivered
more frequently at intervention practices.
Study Design: Practice-level randomized controlled trial.
Outcome measures were the proportion of adult smokers who
reported cessation counseling (provider advice to quit and/or
a discussion of ideas or plans to facilitate quitting) during a
practice visit, as determined in an anonymous exit survey
administered at the conclusion of the visit. Following a sixweek baseline assessment of counseling rates, 18 practices
were placed into 5 matched groups with similar counseling
rates. Within each matched group, practices were assigned
randomly to intervention or control groups. Counseling rates
were monitored for six months. Intervention practices
received periodic feedback on protocol adherence. Outcomes
(mean counseling rates) for the control and intervention
practices were contrasted utilizing a hierarchical logistic
regression model that accounted for variation among
practices, variation among providers within practices, and
variation among a provider’s patients. We weighted practice
data to adjust for uneven sampling volume of patients over
time. Our analysis also accounted for each practice’s baseline
counseling rate, weighted to match the provider distribution
during the comparison period. Data from providers not
present in both baseline and comparison time periods were
excluded.
Population Studied: Eighteen primary care practices (family
medicine and/or internal medicine) in the greater Richmond,
Virginia area, including 2 urban, 2 rural, and 14 suburban
locations. Baseline exit surveys were completed by 2146
patients (384 smokers). Comparison-period exit surveys were
completed by 6786 patients (1164 smokers). Participation was
81%.
Principal Findings: Most intervention practices had no
difficulty implementing the vital sign protocol. Receipt of
cessation counseling increased significantly at intervention
sites (8.5%, p=0.038), due primarily to increased receipt of
simple advice to quit (8.4%, p=0.039). The intervention did
not significantly increase delivery of more intensive discussion
of how to quit (p=0.178). The intervention and resulting
changes in counseling appeared to be sustained over the sixmonth period.
Conclusions: Smokers visiting intervention practices were
more likely to receive cessation counseling than those visiting
control sites, but most of the resulting counseling consisted of
simple advice to quit. Increasing the delivery of intensive
counseling to smokers probably requires more extensive
practice redesign than reminder systems (e.g., vital sign)
alone.
Implications for Policy, Delivery, or Practice: The modest
effect on simple advice (8.5%) that we observed should not be
discounted. Given certain assumptions, we estimate that a
practice of four providers could produce an ex-smoker every 67 weeks by adopting this intervention. However, additional
measures must be adopted in primary care, either through
expanded practice resources or partnerships with community
services, to give smokers the assistance they need.
Primary Funding Source: RWJF
●Does an Internist Psychiatric Collaboration for the
Management of Psychiatric Inpatients Improve Patient
Care
Alan Rubin, M.D., Benjamin Littenberg, M.D., Robert Ross,
PhD, Susan Wehry, M.D., Marilee Jones, BA
Presented By: Alan Rubin, M.D., Reseach Associate Professor
of Medicine, Primary Care Internal Medicine, UVM College
Medicine- FAHC, 371 Pearl Street, Burlington, VT 05401; Tel:
(802)847 8268; Fax: (802)847 0319; Email:
alan.rubin@uvm.edu
Research Objective: To study the effects of an internistpsychiatrist collaboration on the processes and cost of care in
patients hospitalized for mental illness.
Study Design: We performed a randomized controlled study
on the inpatient units of an academic medical center. Patients
in the intervention group met with a study internist who
participated in their care by communicating with their primary
care physicians, updating health maintenance and preventive
endpoints, managing chronic and acute medical problems,
and attending hospital work rounds. Control subjects received
usual care. We measured the process of care using provision
of services, coordination of care, and completion of health
maintenance endpoints. We measured resource utilization
using charges and length of stay.
Population Studied: We studied 139 adults admitted during a
nine month period for a variety of mental health problems
requiring admission.
Principal Findings: Patients in the intervention group showed
improvement in processes of care (numerous measures with
P< 0.001). Overall, there were no changes in charges or length
of stay.
Conclusions: Adding an internist to an inpatient psychiatric
team is an effective way of improving care for this traditionally
underserved population without increasing cost.
Implications for Policy, Delivery, or Practice: A
collaboration of a medical p[ractitioner with psychiatric teams
may be a way to improve care without increasing cost
Primary Funding Source: Fletcher Allen Health Care
●Reducing Psychotropic Drug Costs while Maintaining
Quality
Karen Shore, Ph.D., Sandra Forquer, Ph.D., Mary Tierney,
M.D.
Presented By: Karen Shore, Ph.D., Senior Research Scientist,
Health Program, American Institutes for Research, 1791
Arastradero Road, Palo Alto, CA 94304; Tel: (650)843-8121;
Fax: (650)858-0958; Email: kshore@air.org
Research Objective: To identify and describe effective ways to
reduce prescription drug costs, with emphasis on
psychotropic drugs, that maintain quality of care and do not
restrict access to specific medications.
Study Design: We identified state Medicaid efforts to manage
prescription drug costs, including mandating the use of
generics, limiting the number of prescriptions that may be
filled in a single month, imposing beneficiary co-payments,
requiring prior authorization, and using fail-first policies. We
then reviewed innovative prescription drug programs in four
states.
Population Studied: We reviewed programs in Pennsylvania,
Missouri, Texas, and Massachusetts. Strategies for managing
drug costs in these states include: an educational intervention
and outlier management program designed to align physician
prescribing practices with best practice guidelines for
prescribing; the development of evidence-based treatment
guidelines for three major psychiatric disorders –
schizophrenia, major depressive disorder, and bipolar
disorder; and the identification and reduction of polypharmacy
– the use of multiple drugs that treat the same condition, are
in the same chemical class, or have similar underlying
pharmacology to treat different conditions.
Principal Findings: The Medicaid programs in Pennsylvania
and Missouri experienced reductions in: 1) polypharmacy; 2)
prescriptions from multiple prescribers; 3) therapeutic
duplication of atypical antipsychotics (use of more than one
atypical antipsychotic drug), and 4) per member/per month
costs. In Texas, the use of evidence-based guidelines resulted
in: 1) faster responses to treatment 2) greater reductions in
negative symptoms, and 3) more effective maintenance of
positive outcomes over time. In Massachusetts, the Medicaid
program has begun to educate prescribers about the costs of
various prescribing patterns as well as the threat that
escalating prescription drug costs pose to enrollee access to
these drugs. The Medicaid program also has identified the
physicians who are outliers (i.e., those who routinely use
polypharmacy approaches) and will work to educate them
about their prescribing practices and the evidence base as it
relates to the type of patients they treat.
Conclusions: Medication management approaches that focus
on quality improvement and the implementation of best
practice guidelines in prescribing can produce both improved
patient outcomes and cost savings.
Implications for Policy, Delivery, or Practice: Access to
psychotropic drugs is an important factor in successfully
treating individuals with certain mental illnesses. In an effort
to manage health care costs, many states have turned to
restrictive practices that limit the availability of these drugs.
This study presents various alternatives for states to limit
prescription drug costs, while still maintaining quality of care
for beneficiaries.
Primary Funding Source: SAMSHA Center for Mental Health
Services
●Relationships Between Residential Substance Abuse
Program Characteristics and Smoking Policies/Services
Karen Shore, Ph.D., Andrea Burling, Ph.D., Thomas A. Burling,
Ph.D., Christine Timko, Ph.D., Roger E. Levine, Ph.D.
Presented By: Karen Shore, Ph.D., Senior Research Scientist,
Health Program, American Institutes for Research, 1791
Arastradero Road, Palo Alto, CA 94304; Tel: (650)843-8121;
Fax: (650)858-0958; Email: kshore@air.org
Research Objective: To identify relationships between 1)
adult residential drug/alcohol (DA) program characteristics
and 2) smoking policies and services. This is part of a large,
nationally-representative survey of residential DA programs
that is examining their smoking and DA use policies and
services, and the impact of these things on DA treatment
outcomes.
Study Design: A stratified random sample of programs
(community- vs. hospital-based program and high vs. low
state tobacco orientation) was selected from SAMHSA’s
Substance Abuse Treatment Facility Locator.
Population Studied: 372 surveys were sent to eligible
programs providing adult residential rehabilitation services
and 274 were returned (74% response rate).
Principal Findings: We recently completed data collection
and are beginning analysis of our final dataset. Preliminary
descriptive data from a subset of 227 surveys are presented
here. PROGRAM CHARACTERISTICS: Most programs are
relatively small (median 25 beds) and are in private, not-forprofit agencies (71%). The average length of stay is 2 months.
Most programs (82%) have complete DA abstinence as their
treatment goal. The primary treatment models used are 12step (42%), cognitive-behavioral (32%), and therapeutic
community (13%). SMOKING POLICIES AND SERVICES:
Almost all programs (98%) have client smoking policies, and
most (68%) have policies related to other tobacco products.
In programs with smoking policies, very few (9%) allow
indoor smoking; most (91%) allow outdoor smoking. A small
but notable number (9%) do not allow it inside or outside.
Programs use multiple methods to inform clients about the
smoking policies that apply to them. Almost all use verbal
(99%) and written (93%) methods and provide information
upon admission (97%). For first time policy violations,
almost all programs (90%) give clients feedback, and 21%
might discharge a client. For multiple violations, the
consequences used are more varied and likely to be more
severe (e.g., 52% might discharge). Smoking cessation is not
emphasized as a treatment goal for clients or is emphasized
only slightly in over half of the programs (55%). In most
programs, few or no staff have received formal training in
smoking cessation. Smoking cessation services are available
to clients in most programs either directly within the program
or through connections made possible by it (76%), but only
about 25% of clients received any such services in the 12
months prior to our survey.
Conclusions: Our preliminary analyses suggest that most
residential DA programs now attend to and address smoking
and smoking cessation. Further analyses of the relationships
between program characteristics and smoking
policies/services will be presented at the conference.
Implications for Policy, Delivery, or Practice: There has
been increasing interest in implementing smoking policies
and services in DA programs due to the high prevalence of
smoking among DA abusers, recognition that DA abusers
who smoke are particularly susceptible to the negative health
consequences of their addictions, and growing movements
towards restricting smoking in healthcare and workplace
settings. The results from this study will supply vital
information that can be used to guide the development and
implementation of these policies/services, and maximize their
effectiveness.
Primary Funding Source: RWJF
●Psychiatrists’ Views of Evidence-Based
Recommendations for the Treatment of Schizophrenia
Elizabeth A. Skinner, MSW, Donald M. Steinwachs, Ph.D.,
Anthony F. Lehman, M.D., MSPH, Maureen Fahey, M.L.A.
Presented By: Elizabeth A. Skinner, MSW, Associate Scientist,
Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 624 North Broadway, Baltimore, MD
21205; Tel: (410)614-4022; Fax: (410)-955-0470; Email:
askinner@jhsph.edu
Research Objective: There is substantial evidence that quality
of care for schizophrenia falls short of evidence-based
standards. Studies of non-adherence to guidelines for other
conditions have found lack of knowledge, disagreement with
the evidence, lack of confidence in ability to implement
guidelines effectively, and perceived organizational barriers to
their implementation. Reasons for the gap between practice
and evidence are not known for schizophrenia. This study
examines the views of practicing psychiatrists concerning five
current recommendations for managing schizophrenia, and
whether treatment type (pharmacological or psychosocial) or
patient, physician or practice characteristics are associated
with variations.
Study Design: A mail survey of practicing psychiatrists
presented five schizophrenia treatment recommendations
recently revised by the Schizophrenia PORT. For each,
respondents rated on a seven point scale factors that might
facilitate or impede its adoption in practice: (1) daily dose
ranges for conventional antipsychotic medications for an
acute symptom episode, (2) antidepressant treatment for
depression, (3) cognitive behaviorally oriented psychotherapy,
(4) family interventions, and (5) supported employment.
Population Studied: Samples of practicing psychiatrists in
Maryland and nationally were surveyed. In Maryland, all 61
psychiatrists in rural areas were selected, plus a one-third
random sample of the remainder (N=539). The national
sample consisted of 100 psychiatrists in rural areas and 300 in
non-rural areas. Response rates were 53% for the Maryland
sample and 39% nationally. In both samples, about threefourths of respondents were engaged in direct patient care
and 60% in office-based practice. 256 respondents had treated
patients with schizophrenia in the previous 5 years.
Principal Findings: Respondents clearly distinguished among
the recommendations in their ratings. While the majority
(66%-80%) agreed (gave ratings of 6 or 7) with all five and
also considered that patient outcomes would improve (51%79%), only the two recommendations involving
pharmacologic treatments were seen as acceptable to patients
(55%-61% vs 19%-36% for the psychosocial
recommendations), easy to implement (57%-63% vs 8%-21%),
and similar to practices of other psychiatrists in the
community (55%-61% vs 19%-36%). Patient caseload
characteristics (race, Medicaid, schizophrenia diagnosis,
number seen per week) were not associated with ratings, nor
were most practice or physician characteristics (urban/rural
location, academic appointment, physician race, years since
residency). However, psychiatrists spending more than half
their time in solo practice gave significantly lower ratings in
several instances, even when patient, physician and other
practice characteristics were controlled in multivariate
analyses. Notably, these psychiatrists were more likely to say
their patients would find unacceptable all the
recommendations except family interventions.
Conclusions: Psychiatrists show variability in their views of
evidence-based recommendations for schizophrenia, with
more favorable views expressed for those involving
pharmacologic management than for psychosocial
treatments. Psychiatrists in solo practice are less likely to have
favorable views, particularly about expectations of their
patients’ acceptance of these treatments. These results will be
used in selecting focus groups to explore barriers in more
depth.
Implications for Policy, Delivery, or Practice: While
attitudes and perceptions may not match practices,
understanding psychiatrists views of treatment
recommendations and barriers for their implementation is a
first step in developing targeted interventions aimed at
helping clinicians bring their practices into greater
concordance with evidence-based guidelines.
Primary Funding Source: National Institute of Mental Health
●Variation on Health-Related Quality of Life (HRQOL)
Associated with Antiretroviral Medication Adherence
among HIV/AIDS Patients with Mental Health and/or
Substance Abuse Problems
Carleen Stoskopf, Sc.D., MS, Yunho Jeon, MS, Jong Deuk
Baek, Ph.D.
Presented By: Carleen Stoskopf, Sc.D., MS, Professor, Health
Services Policy and Management, University of South
Carolina, 800 Sumter Street, Suite 116, Columbia, SC 29208;
Tel: (803)777-4781; Fax: (803)777-1836; Email:
cstoskopf@sc.edu
Research Objective: To determine the health-related quality
of life associated with antiretroviral adherence among
HIV/AIDS patients with mental health and/or substance
abuse problems, controlling for socioeconomic, demographic,
and clinical variables.
Study Design: This is a cross-sectional study, using the HIV
Cost and Services Utilization Study (HCSUS) data. The
dependent variables are physical and mental quality of life
indicators. A linear regression was performed, controlling for
social, economic, demographic, and clinic variables. The
independent variable of interest is adherence to antiretroviral
therapy.
Population Studied: A national probability sample of 2,466
adults receiving HIV care (HCSUS) who completed first
follow-up interviews from December 1996 to July 1997.
Principal Findings: HIV patients reporting mental health and
substance abuse problems had significantly lower scores on
both physical and mental health quality of life measures than
those not reporting such problems. The quality of life score is
significantly higher for patients reporting only substance
abuse problems than those reporting only mental health
problems and those reporting both mental health and
substance abuse problems.
Those HIV patients who indicated good adherence to
antiretroviral treatment had significantly higher physical and
mental health quality of life scores. However, when
controlling for mental health and substance abuse problems,
the association is not consistent.
Conclusions: Quality of life among HIV/AIDS patients may
not be improved by adhering to stringent drug therapies,
especially for those with co-morbidities such as mental illness
and substance abuse.
Implications for Policy, Delivery, or Practice: Strict
adherence to antiretroviral treatment is required in order to
prolong life among those who are HIV positive, and limit
transmission of HIV to others. However, adherence is often
difficult over long periods of time, and may not result in
improved physical and mental health quality of life. This is
especially true for those with co-morbidities such as mental
illness and substance abuse. This situation presents a
challenge to the medical community in gaining compliance to
treatment regimens.
Primary Funding Source: No Funding
●Studying Diffusion of a Model Indicated Prevention
Program in a Multi-site Effectiveness Yrial
Samruddhi Thaker, MBBS, MHA, Allan Steckler, Dr.PH.,
Shereen Khatapoush, Ph.D., Denise Hallfors, Ph.D., Victoria
Sanchez, Dr.PH., John Rose, MPH
Presented By: Samruddhi Thaker, MBBS, MHA, Research
Associate and Doctoral Student, Pacific Institute for Research
and Evaluation and UNC-CH, 1516 East Franklin Street, Chapel
Hill, NC 27514; Tel: (919)265-2633; Email:
sthaker@email.unc.edu
Research Objective: A critical issue in health services
research and prevention science is the development and
dissemination of research-tested programs to promote
effective practice. While extensive resources have been
devoted to efficacy trials for the development and testing of
these programs, relatively little have been spent on
effectiveness trials and diffusion studies to understand what
happens when programs are implemented in real world
settings. Yet both are critical to understanding the gap
between research and practice. Over the last two decades, a
growing cadre of school-based prevention programs has
shown, under rigorous experimental conditions, the ability to
prevent or reduce substance use and other high risk behaviors
among adolescents. However, these programs are complex to
deliver, and require substantial organizational innovation. For
widespread adoption, implementation, and diffusion of
indicated programs in schools, evidence of positive student
outcomes from efficacy trials has been insufficient. We
conducted an effectiveness trial of Reconnecting Youth (RY),
an indicated prevention program in two large, urban, diverse
school districts in the United States. We describe the design
and findings of this study conducted to examine the factors
predicting the adoption and implementation of RY.
Study Design: We collected data through quantitative self
administered questionnaires, followed by qualitative interviews
with district- and school-level administrators and RY teachers
at one-year intervals. Our analyses are based on two data
points for each district, assessing variables including: school
climate and culture, organizational capacity, organizational
turbulence, staff turnover, training, administrative leadership,
presence of a program champion, communication and
perceived characteristics of the program.
Population Studied: Ten schools in two districts are the unit
of analysis.
Principal Findings: A total of 10 schools (5 per district)
participated in the study. In site A, two schools dropped out
after the first semester. Both schools lacked a program
champion, and the program faced opposition from guidance
counselors and lacked leadership support. In site B, one
school dropped out after the first semester. Primary reasons
were organizational turbulence and staff turnover. At the end
of the three-semester effectiveness trial, only one school in
site A and two schools in site B continued the program. As
predicted by the diffusion of innovation framework, several
perceived program characteristics and organizational factors
affected adoption and diffusion of the program.
Conclusions: Schools faced many barriers impeding the
adoption and implementation of this complex model
program. Primary among these barriers were difficulty with
teacher selection, student selection and recruitment, lack of
adequate resources, competing priorities, organizational
turbulence and staff turnover. Several program characteristics
counteracted the perceived effectiveness of RY, thus
influencing schools' decision to discontinue the program at
the end of the trial. Schools in both districts had difficulty
implementing the program, even when resources in the form
of technical assistance and evaluation were provided.
Implications for Policy, Delivery, or Practice: Positive
results from efficacy trials are not sufficient for the adoption,
implementation and diffusion of indicated programs to help
at-risk students. Organizational factors and program
characteristics play a significant role in predicting diffusion of
innovative programs.
Primary Funding Source: NIDA
●Patterns and Correlates of Psychotropic Use Among
Adolescents
Lynn Warner, Ph.D., Cynthia Fontanella, Ph.D., Kathleen
Pottick, Ph.D.
Presented By: Lynn Warner, Ph.D., Assistant Professor,
School of Social Work, Rutgers University, 536 George Street,
New Brunswick, NJ 08901; Tel: (732)932-5064; Fax: (732)9326872; Email: lywarner@rci.rutgers.edu
Research Objective: This paper describes patterns and
predictors of psychotropic medication in adolescent
psychiatric inpatient settings, where the purpose of care is to
stabilize youths and return them as quickly as possible to less
restrictive and less expensive service settings. Additionally, we
investigate the possibility that pressures for rapid discharge
operate differently depending on the presence or absence of
an adolescent’s medication use prior to hospitalization.
Specifically, decisions to initiate a psychotropic regimen are
most likely to be based on clinical characteristics (e.g.,
diagnosis of a mood or psychotic disorder, danger to self or
others), and decisions to augment a medication regimen by
adding a class of drugs not already prescribed for an
adolescent (polypharmacy) are likely to be based on
characteristics that speak to adherence (fidelity to prescribed
regimen, presence of substance abuse, instability of living
situation).
Study Design: A longitudinal inpatient cohort followed for
one year after discharge. In-depth data were collected from
medical records and merged with Medicaid claims data.
Population Studied: Universe of adolescents (ages 11 to 17)
admitted to one of three free-standing private psychiatric
hospitals (two nonprofit and one for-profit) in Maryland
between July 1, 1997 and June 30, 1998, who lived in the state
and were eligible for Medicaid at the time of the index
admission (n=522).
Population Studied: Universe of adolescents (ages 11 to 17)
admitted to one of three free-standing private psychiatric
hospitals (two nonprofit and one for-profit) in Maryland
between July 1, 1997 and June 30, 1998, who lived in the state
and were eligible for Medicaid at the time of the index
admission (n=522).
Principal Findings: Almost two-thirds (62.6%) of the
adolescents had been prescribed a psychotropic medication in
the month prior to the index admission; by discharge, 89.7%
of the adolescents were treated with at least one psychotropic
medication. The mean number of medications increased
from 1.4 to 1.9. Overall, more than half (55.2%) of the
adolescents were introduced to a new class of drug during
their hospitalization, including the 27.7% without a prior
prescription. Characteristics that significantly increased the
odds of initiating any medication among those without a
history of medication (n=195) included diagnosis (mood and
behavioral disorders vs. adjustment disorder), substance
abuse, symptom severity, suicidality and dangerousness. The
only predictor that significantly increased the odds of the
addition of a new class of medication to a pre-existing
regimen was mood disorder; two predictors were associated
with significantly lower odds of new medication (suicidality
and number of prior medications). The strongest predictors
of both initiation and new medication were hospital and
length of stay.
Conclusions: Clinical profiles differ for youths with no prior
medication history compared to youths who have already
initiated a psychotropic medication regimen. As expected,
more severe emotional disturbance predicted initiation.
Contrary to expectations, predictors reflecting medication
adherence were not important in the addition of new
medication. However, for both groups of adolescents,
treatment setting (specific hospital) was the strongest
predictor of medication onset and augmentation.
Implications for Policy, Delivery, or Practice: Interventions
to ensure the development and implementation of medication
management guidelines need to be targeted at the
organizational level as well as directly to individual
practitioners.
Primary Funding Source: Center for Health Care Strategies
through the Annie E. Casey Children's in Managed Care
Initiative
●The Utility and Cost-Utility of Treatments for Major
Depression
Katherine E. Watkins, M.D., MSHS, Audrey Burnam, Ph.D.,
Maria Orlando, Ph.D., Jose Escarce, M.D., Ph.D., Howard
Goldman, M.D.
Presented By: Katherine E. Watkins, M.D., MSHS, Natural
Scientist, RAND Health, RAND Corporation, 1776 Main Street,
Santa Monica, CA 90407; Tel: (310)393-0411 x6509; Fax:
(310)260-8150; Email: kwatkins@rand.org
Research Objective: In this paper we report on a new
methodology to obtain utility estimates of the health value of
commonly prescribed treatments, and apply this approach to
treatment patterns and patient characteristics found in usual
care for major depression. We also use claims data to obtain
the costs of each treatment, and report cost/utility ratios.
Study Design: We developed a modified expert panel
approach to estimate the utility of different patterns of care for
major depression. Thirteen panelists estimated three sets of
utility ratings: before treatment, 3 months after no new
treatment (natural history ratings), and 3 months after a
prescribed treatment; the change between the after treatment
and the natural history ratings was the utility of treatment. We
used MEDSTAT claims and pharmacy data from 1998-2000 to
identify common treatment patterns, and provided panel
members with summary information on treatment
effectiveness. Ratings were elicited using a web tool; panelists
made independent initial ratings, met to discuss
disagreements and then made re-ratings. We also used the
claims and pharmacy data to estimate the costs of treatment.
Population Studied: We defined 18 treatment patterns after
an index visitfor major depression in terms of number of
psychotherapy visits, use of a non-tricyclic antidepressant
medication for more than 30 days, whether the patient
received a medication follow-up visit, and days of
sedative/hypnotic use. These treatment patterns were applied
to six patient groups aged 18-55 defined in terms of the
severity and chronicity of the depressive episode.
Principal Findings: For mild depression, the utility of
antidepressants with a medication follow-up visit is equivalent
to 10+ psychotherapy visits. For severe depression, treatment
with medication produces a larger gain in utility than 10+
psychotherapy visits, with combination therapy producing the
largest gains. For all severity levels, combination treatment
with psychotherapy and an antidepressant produces the
largest gains. The lowest cost treatment, 1-3 psychotherapy
visits, produces minimal improvement in utility. Treatments
which include an antidepressant medication with a medication
follow-up visit dominate all other treatments, and produce the
most utility for a given cost. Adding an medication follow-up
visit to an initial medication visit produces the largest gain in
utility for the least cost. Additional gains in utility can be
achieved by adding psychotherapy visits to treatment with
antidepressants but these gains are modest with respect to
the additional costs.
Conclusions: Although costs remain constant across different
levels of patient severity and chronicity, utility increases as
severity increases. This suggests that treatments should be
targeted at sicker patients. Providers and policy makers
looking to increase the cost-utility of their treatments should
focus on ensuring that all patients on antidepressant
medication receive a medication follow-up visit.
Implications for Policy, Delivery, or Practice: We describe a
low-cost and efficient methodology of obtaining estimates of
utility by combing the best available scientific evidence with
the collective judgment of experts. By having information on
the value as well as costs of routine practice and best practice,
we hope to be able to identify ways in which quality
improvement efforts could have the most impact for a given
cost.
Primary Funding Source: MacArthur Foundation
●Relationship Between Desire to Talk to Doctor, Trust in
Doctor, and Willingness-to-Participate in HIV Vaccine
Trials
Shinyi Wu, Ph.D., Sai Ma, MPA, Naihua Duan, Ph.D., Sung-Jae
Lee, Ph.D., Danielle Seiden, MPP, Peter A. Newman, Ph.D.
Presented By: Shinyi Wu, Ph.D., Associate Engineer, Health,
RAND Corporation, 1776 Main Street, Santa Monica, CA
90401; Tel: (310)393-0411; Email: shinyi@rand.org
Research Objective: The development of efficacious HIV
vaccines offers the best long-term hope of controlling the
AIDS pandemic. Trial participation is critical for the success of
the vaccine development, but many concerns hinder people’s
willingness-to-participate (WTP). The present study examined
the potential role a doctor may play in facilitating future trial
recruitment.
Study Design: An innovative cross-sectional survey of the
population at elevated risk for HIV. The study used a fractional
factorial experimental design to construct eight hypothetical
HIV vaccine trials that vary across seven dichotomous
attributes. The survey respondents rated their likelihood of
participation in each of the hypothetical trials. Mean WTP
score was calculated across the eight ratings for each
respondent. The survey also included questions on the
respondents’ desire to talk to their own doctors before
participating in a HIV vaccine trial, as well as their trust and
mistrust in doctors. Multiple regressions were used to explore
the relationships between desire to talk to doctor,
trust/mistrust, and the WTP, after controlling for individual
characteristics.
Population Studied: 123 individuals recruited from three
gay/lesbian community centers, three needle exchange sites,
and three Latino primary care clinics in Los Angeles.
Principal Findings: The mean WTP score was 40.5 (SD 22.1)
on a 0-100 scale where higher score represents greater WTP.
Men were more willing to participate in a HIV vaccine trial
than women (p < .05), while having high school or higher
education reduced the WTP (p< .10). Three out of four survey
respondents expressed desire to talk to their own doctors
before participating in a HIV vaccine trial. This variable is
significantly, but negatively, associated with their WTP (p<
.01). The respondents who highly trusted their doctor or clinic
to put their health above all other concerns rated higher WTP
(p < .05). Nevertheless, the respondents who had higher
mistrust in doctors, i.e., who believed that they or people like
them might be used as guinea pigs for medical research
without their consent, were also more willing to participate in
the hypothetical trials.
Conclusions: Overall willingness to participate in a HIV
vaccine trial was low. The majority of study people wanted to
talk to their own doctor before participating in a trial. The
negative relationship between desire to talk to doctor and
WTP in trial implies that a doctor is very likely to influence a
low WTP person’s decision for trial participation. The result
that greater trust in providers is associated with higher WTP
score indicates that positive medical experience can mitigate a
person’s concern for trial participation. The persons with
greater mistrust, however, might be subject to a risk-seeking
behavioral pattern, i.e., they are vulnerable population and
thus they are more willing to take the risk of HIV vaccine trials
for health (free care) or financial (receiving monetary
incentive) reason.
Implications for Policy, Delivery, or Practice: Persons at risk
for HIV have low willingness to participate in HIV vaccine
trials. Our study found that doctors might play an important
role in facilitating future HIV vaccine trial recruitment through
communication and a trustworthy relationship with their
patients.
Primary Funding Source: UCLA AIDS Institute Seed Grant
from a grant to the UCLA California AIDS Research Center
(CC99-LA-002).
●A Consumer-Led Intervention that Improves Mental
Health Provider Quality
Alexander Young, M.D., MSHS, Matthew Chinman, Ph.D.,
Sandra Forquer, Ph.D., Edward Knight, Ph.D., Howard Vogel,
CSW, CASAC, Anita Miller, Psy.D.
Presented By: Alexander Young, M.D., MSHS, Associate
Professor, West LA VA, MIRECC, UCLA Neuropsychiatric
Institute, 11301 Wilshire Boulevard, 210A, Los Angeles, CA
90073; Tel: (310) 268-3416; Fax: (310) 268-4056; Email:
a1young@earthlink.net
Research Objective: Client-centered care is a major aim of
healthcare. In mental health, The President’s New Freedom
Commission has established national goals that include
improving access to client-centered, recovery-oriented
treatment. New treatment approaches emphasizing
rehabilitation, and empowerment had been shown to improve
outcomes for people with severe, persistent mental illness.
However, these approaches are not widely used, in part
because many practicing clinicians lack the necessary
competencies. There is an emerging national movement of
mental health consumers that has been developing
interventions to improve care. The objective of this study was
to evaluate the effectiveness of an innovative intervention,
“Staff Supporting Skills for Self-Help,” which was developed
and led by consumers with the goal of improving provider
quality, empowering consumers, and promoting mutual
support.
Study Design: A national consensus process identified 37
core clinical competencies that are critical to the provision of
quality care to people with serious mental illness. Of these, 16
competencies were selected as the focus for this study, based
upon being central to recovery-oriented care. The study was
conducted at five large community mental health
organizations in Colorado and Arizona. Funding for these
organizations is managed by ValueOptions, a behavioral
managed care company. The intervention included education,
clinician-client dialogues, ongoing technical assistance and
support of self-help. A one-year controlled trial evaluated the
effect of the intervention on clinicians’ competencies
(knowledge, skills, attitudes), care processes, and the
formation of mutual support. Outcomes were assessed using
the Competency Assessment Instrument and Recovery
Attitudes Questionnaire, and semi-structured interviews with
clinic staff and consumers. The Competency Assessment
Instrument has been previously shown to be a reliable and
valid method for measuring the relevant competencies.
Change over time was compared between the intervention
and control groups using covariance analyses.
Population Studied: Clinicians working at 16 sites of large
community mental health organizations, and consumers
receiving care from the same sites.
Principal Findings: Of 340 eligible clinicians, 269 (79%)
chose to participate. Two thirds of these clinicians
participated in at least one intervention component.
Clinicians at intervention sites showed significant
improvement (p<.05) in stigma, client preferences,
medication management, holistic approach, optimism,
education about care, rehabilitation methods, natural
supports, and overall competency. Compared with controls,
improvement was significantly greater under the intervention
for education about care (F=6.9), rehabilitation methods
(F=4.5), natural supports (F=2.9), medication management
(F=3.6), team-work (F=3.9), overall competency (F=4.4), and
recovery orientation (F=4.3). Magnitude of exposure to the
intervention was correlated with improvement for each of
these competencies (p<.05, r=0.21 to r=0.28). At intervention
sites, rehabilitation techniques were incorporated into
practices, and 8 mutual support groups formed.
Conclusions: A feasible, consumer-led intervention improves
self-help and provider competency in domains that are
necessary for the provision of high quality care.
Implications for Policy, Delivery, or Practice: Approaches
similar to this intervention can help policy makers and
provider organizations improve provider quality and transition
to consumer-centered care models that support recovery.
Having a competent workforce does not ensure that
appropriate care is provided, but it represents an important
first step.
Primary Funding Source: RWJF
●Stakeholder Perspectives on Integrated Mental Health
Services in Primary Care Settings
Cynthia Zubritsky, Ph.D., Hongtu Chen, Ph.D., Joseph Gallo,
Ph.D, James Maxwell, Ph.D., Karen Cheal, MPH, Jack
McIntyre, M.D.
Presented By: Cynthia Zubritsky, Ph.D., Associate Professor,
University of Pennsylvania, 600 Market Street, 7th Floor,
Philadelphia, PA 19104; Tel: (215)662-2886; Email:
cdz@mail.med.upenn.edu
Research Objective: To examine patient satisfaction and
provider perspectives on integrated care versus enhanced
referral models.
Study Design: Older adults aged 65 and above were screened
at primary care clinics from 10 study sites throughout the U.S.
Those who met diagnostic criteria for depression, anxiety,
and/or at-risk alcohol consumption were randomly assigned
to either IC or ES models. We also collected supplementary
data on primary care providers' perspectives on integrated
versus enhanced referral care.
Population Studied: Older adult (over 65 years old) users of
primary care services at eleven study sites throughout the
country. Study settings included community health centers,
VA facilities, and other community primary care clinics.
Over 25,000 older adults were screened for mental health and
alcohol drinking problems in primary care settings. More than
2,200 elderly primary care patients with depression, anxiety,
and at-risk drinking participated in this study.
Principal Findings: Older primary care patients who
participated in PRISM-E reported significantly higher
satisfaction with the integrated mental health care than with
the enhanced specialty referral care. Patients who attended the
treatment service twice or more were more likely to feel
satisfied with the IC than ESR. A reduction in depression
symptoms as measured by a decrease in CES-D score was
significantly associated with patient satisfaction for the subset
of patients with depression but clinical outcome was not
predictive of patient satisfaction for those with at-risk drinking.
Conclusions: This finding suggests that overall primary care
patients would prefer mental health services delivered in the
primary care setting. Primary care physicians, in general,
preferred the integrated model across several domains. They
reported that integrated care led to better communication
between PCPs and MH providers, less stigma, and better
coordination of mental health and general health care. Mental
health clinicians also have positive views of how an integrated
model will improve access to mental health services, although
they have more confidence in the quality of treatment
provided by the enhanced specialty referral, especially for
patients with major depression.
Implications for Policy, Delivery, or Practice: The study
shows that patient satisfaction is often more dependent on
patient preferences than actual clinical outcomes. This
supports policy analysts' move for choice of care.
Primary Funding Source: SAMHSA