Behavioral Health
Call for Papers
Organizational Influences on Quality of
Behavioral Health Care
Chair: Michael Von Korff, Group Health Cooperative
Sunday, June 25 • 5:45 pm – 7:15 pm
●Effectiveness and Cost-Effectiveness of Collaborative care
Depression Treatment in Veterans who Screen Positive for
PTSD in Primary Care
Domin Chan, PhC, Chuan-Fen Liu, Ph.D., Edmund F. Chaney,
Ph.D., Susan Hedrick, Ph.D.
Presented By: Domin Chan, PhC, Research Health Science
Specialist/student, UW Health Services, VA Puget Sound
HCS, HSR&D, 1100 Olive, Suite 1400, Seattle, WA 98101; Tel:
(206)277-4159; Fax: (206)764-2935;
Email: domin.chan@va.gov
Research Objective: Depressed patients with comorbid PTSD
may be more functionally impaired than patients with
depression alone and may need more intensive mental health
treatment. This study compared the effectiveness and costeffectiveness of collaborative care depression treatment for
depressed primary care patients who screen positive for
comorbid post-traumatic stress disorder (PTSD+).
Study Design: These patients were randomly assigned to
collaborative care or usual care by provider group. Under
collaborative care, a mental health team developed a
treatment plan for primary care providers, a social worker
telephoned patients to enhance adherence, and suggested
treatment modifications. Outcomes were measured at three
and nine months by telephone interviews using the Hopkins
Depression Symptom checklist (SCL-20), Sheehan Disability
Scale, and SF-36 Mental Component Score (MCS).
Multivariate regression was used to detect differences in
change scores, adjusting for baseline patient characteristics,
outcome measures, and provider clustering. The costeffectiveness ratios of additional total outpatient cost per
depression-free day were calculated. Confidence intervals for
cost measures and depression-free days were estimated by
bootstrapping with 1000 replications.
Population Studied: A total of 338 patients in a Veteran’s
Affairs primary care clinic were screened for major depression,
dysthymia and PTSD. The study sample included 54%
(n=183) with depression and PTSD positive screen, defined as
experiencing at least two of the following PTSD symptoms: reexperiencing intrusive disturbing images/thoughts,
hyperarousal, or increased avoidance.
Principal Findings: This study shows that PTSD positive
screen interacts with treatment. Depressed PTSD+ patients in
the collaborative care group had significant improvement in
SCL-20 depression score at 3 months (-0.26, p=.003) and at 9
months (-0.19, p=.016) compared to the usual care group,
according to multivariate results. Similarly, at 3 and 9 months,
collaborative care treatment for PTSD+ patients had a
statistically significant improvement in mental health
functioning, measured by mean MCS score. In addition,
treatment improved functioning for PTSD+ patients on the
Sheehan Disability Scale by -0.87 (p=0.02) at 3 months but
not at 9 months. Total outpatient costs for collaborative care
were on average $372 more than usual care; however this was
not statistically significant (95%CI -$115 to $865) for PTSD+
patients. Collaborative care resulted in an additional 17 days
free from depression (95%CI 0.58 to 33) than usual care over
nine months. The incremental cost-effectiveness ratio for
PTSD+ patients was $68 per depression-free day (95%CI -$18,
$167) for total outpatient costs.
Conclusions: Collaborative care resulted in higher
functioning, sustained improvement in depression symptoms;
greater depression-free days and moderately increased
treatment costs for PTSD+ depressed veterans.
Implications for Policy, Delivery, or Practice: This suggests
that collaboration between primary care providers and mental
health specialists and supportive patient care management
may be particularly important for treatment of Veterans with
depression and PTSD symptoms at a cost comparable to
other evidence-based improved care.
Primary Funding Source: VA
●Measuring the Enhancement of Integrated Care
Management for a Medicaid Population with Substance
Abuse and High Medical Expenses: Return on Investment
after One Year
Peter Fagan, Ph.D., Martha Sylvia, RN, MSN, M.B.A., Kenneth
Stoller, M.D., Michael Griswold, PH.D., Pierre Alexandre,
PH.D., MS, Linda Dunbar, PH.D.
Presented By: Peter Fagan, Ph.D., Director of Research and
Clinical Outcomes, Psychiatry and Behavioral Sciences, Johns
Hopkins HealthCare LLC; Johns Hopkins School of Medicine,
6704 Curtis Court, Glen Burnie, MD 20904; Tel: 410 4244958; Fax: 410 424-4958; Email: pfagan@jhmi.edu
Research Objective: This study examines if MCO
coordination and integration of substance abuse outreach and
medical care management of Medicaid recipients who abuse
substances and who are high utilizers of medical services can
have a positive return on investment (ROI).
Study Design: The study is a two-group comparison of an 18
month quality enhancement initiative (QEI). The intervention
group (N = 400) was managed by substance abuse
coordinators (SAC) and nurse case managers who received
ongoing training in the integration of medical case
management and substance abuse services. The comparison
group (N = 203) received usual and customary outreach by
SACs and care management. The study tracked the start-up
costs and operational expenses. It also compared the
utilization and total medical costs for the first 12 months of
the 18 month intervention for the two groups. The research is
being independently evaluated by the University of North
Carolina as part of a ten site study of the business case for
quality among Medicaid recipients.
Population Studied: The population consisted of adults
enrolled in a Medicaid MCO who had serious medical
conditions and who had a recent history of substance abuse.
The morbidity level of the study sample (N = 603) was
selected based on an ACG predictive model score = > 0.39
and a diagnosis of substance abuse during the previous 30
months.
Principal Findings: 1) The intervention group had a reduction
in total medical costs of $207 per member per month
(pmpm) during the first 12 months of the QEI compared to
the 12 months prior to the intervention. The comparison
group experienced an increase of $448 pmpm for the same
two periods of time. The reduction in medical expenses for the
intervention group reflected lower rates per 1000 members in
admissions (334 admissions/1000 fewer) and days admitted
(690 days admitted/1000 fewer). The increase in total
medical expenses in the comparison group reflected an
increase in average length of stay by nearly one day per
admission. 2) The combined expense of $132,271 for the initial
investment ($40,276) and 12 month QEI operational expenses
($91,995) compared with a projected savings ($207 x 4087
member months) of $846,009 resulted in a positive ROI. 3)
The intervention group had an increase in members receiving
substance abuse treatment and enrolling in case
management. The numbers are from the initial analyses.
Conclusions: Preliminary data support: 1) Integrated care
management, combining medical and substance abuse case
management, provided to medically compromised and
potentially substance using Medicaid recipients can have a
positive ROI; 2) utilization indicators such as reduction of
admissions and increases in enrollment in care management
and substance abuse treatment suggest that this ROI can be
achieved while enhancing the quality of care that the members
are receiving.
Implications for Policy, Delivery, or Practice: Preliminary
evidence supports: 1) Medicaid MCOs continued integration
of behavioral and medical outreach and care management; 2)
State Medicaid agencies removing system barriers that
impede the integration of behavioral and medical care for
recipients.
Primary Funding Source: Center for Health Care Strategies
through a separate grant to CHCS by The Robert Wood
Johnson Foundation
●Novel Concepts in Tobacco Research: Organizational
Culture and the Chronic Care Model
Dorothy Hung, Ph.D., M.A., M.P.H., Donna R. Shelley, M.D.,
M.P.H.
Presented By: Dorothy Hung, Ph.D., M.A., M.P.H., Research
Scientist, Sociomedical Sciences, Columbia University,
Mailman School of Public Health, 722 W. 168th Street, Suite
526B, New York, NY 10032; Tel: (212) 342-0154; Fax: (212) 3429097; Email: dh2237@columbia.edu
Research Objective: Previous studies of provider behavior
have focused on individual characteristics, yet implementation
of clinical guidelines is often impacted by practice
environment and availability of comprehensive care systems.
This research explores the relationship between organizational
culture and implementation of the “5A” clinical guidelines.
Additionally, the Chronic Care Model (CCM) is examined as a
template for increasing 5A guideline adherence while
providing an appropriate framework for tobacco dependence
as a chronic illness.
Study Design: Self-administered surveys were conducted
among healthcare providers and the community health clinics
in which they work. Providers responded to survey questions
regarding their 5A practice patterns, and to questions derived
from a validated instrument for evaluating organizational
culture in healthcare settings. Individual responses were
aggregated to the clinic level to obtain a composite measure
of organizational culture. At the clinic level, medical directors
completed a survey assessing the availability of system
components based on the CCM. Multilevel modeling will be
used to estimate provider behavior as a function of predictors
at both individual and organizational levels. Data collection is
currently underway, with an estimated final study sample of
approximately 1000 providers and 85-100 clinics in NYC.
Preliminary results are based on a 90% response rate.
Population Studied: Primary care providers; Community
health clinics.
Principal Findings: Delivery of the 5As was positively
associated with a rational organizational culture emphasizing
task performance, achievement, and efficiency (p<0.05). With
regard to the CCM, the 5As were positively associated with
community linkages (p<0.10), measured by whether the clinic
systematically referred patients to community programs and
participated in community tobacco cessation events. The 5As
were also positively associated with the health
system/organization CCM component (p<0.05) measured, for
example, by the existence of a written policy regarding tobacco
identification and financial incentives for providers to treat
tobacco. Decision support including clinician reminder
systems for tobacco treatment, provider feedback on tobacco
patients, and tobacco guideline materials was positively
associated with 5A performance (p<0.10). However, delivery
system design including identifying a tobacco champion,
training clinical support staff to help deliver interventions, and
conducting group tobacco cessation visits was not significant.
Last, both the patient self-management component (e.g.,
pamphlets/self-help materials, tobacco follow-up) and clinical
information systems (e.g., tobacco documentation systems,
registries, chart reviews) were positively associated with 5A
delivery (p<0.05). Final model results from the full sample
will be presented.
Conclusions: This study introduces novel concepts to the
field of tobacco research. Preliminary findings suggest that a
rational organizational culture is associated with improved
provider behavior for tobacco identification and treatment.
More data are needed to discover other culture types that may
impact provider practice patterns. Study results also find that
system elements based on the CCM may be useful in
addressing tobacco care processes.
Implications for Policy, Delivery, or Practice: This research
informs policy efforts to improve care delivery by increasing
compliance with tobacco treatment guidelines. Preliminary
results suggest that organizational values and comprehensive
care systems are important factors that influence provider
behavior.
Primary Funding Source: NYSDOH
●The Three-Minute Mental Health Care: Insights from
Videotapes of Elderly Patients’ Primary Care Office Visits
Involving Mental Health Topics
Ming Tai-Seale, Ph.D., M.P.H.
Presented By: Ming Tai-Seale, Ph.D., M.P.H., Associate
Professor, Health Policy and Management, Texas A&M Health
Science Center School of Rural Public Health, TAMU 1266,
College Station, TX 77843; Tel: 979 845 2387;
Email: mtaiseale@srph.tamhsc.edu
Research Objective: Late-life mental disorders are common,
with the prevalence of major depression at 6-9% and milder
depressive symptoms affecting up to an additional 37% elderly
population. Practice guidelines call for at least four office visits
during which mental health problems are discussed in a sixmonth period. Despite the interest in measuring quality of
mental health care, very few studies have used direct
observation to understand how mental health care is
delivered. Many studies of quality are constrained by their
reliance on global assessments of clinical practices based on
administrative data, patient or physician self-reports, or chart
reviews. When compared with direct observation, those data
have been documented to provide biased representation of
the actual care process. The purpose of this study is to assess
care process using videotapes of office visits involving mental
health topics.
Study Design: Qualitative and quantitative methods were
used to study videotapes of primary care office visits. The
videotapes were coded to obtain data on the nature of the
topics – biomedical, mental health, or psychosocial –
discussed and the time spent on each topic. Quantitative
estimates measured the amount of time physicians and
patients spent on discussing mental health issues and other
issues in each visit. Patient and physician surveys provided
additional information on patients’ health status, physician
specialty, years in practice, and demographics.
Population Studied: Videotapes of 392 elderly patients’ visits
to primary care physicians – covering 2,506 diverse topics – in
three U.S. locations between 1998 and 2000.
Principal Findings: Mental health topics occurred in 20.2% of
visits, accounting for 3.5% of total topics. The average time a
physician spent discussing mental health issues was less than
one minute (58.8 seconds) in comparison to 65.9 seconds on
biomedical topics (p>0.05). A patient spent, on average, 114.8
seconds on mental health topics, compared with 57.2 seconds
on biomedical topics (p<0.01). The range of mental health
topics included depression, general anxieties, and other mood
disorders. Female physicians and family practitioners were
twice more likely to discuss mental health than male and other
physicians, respectively (p<0.01). Critical discourse analysis
suggested that physicians’ effort in treating mental health
issues was no greater than what’s spent on biomedical issues.
In some cases, only perfunctory effort was made on mental
health before physicians redirected the conversation to
biomedical issues. In-depth discussions of psychotropic
medications were uncommon. Very few physicians
recommended psychotherapy or discussed referrals to mental
health specialists.
Conclusions: Only three minutes – one from physicians and
two from patients – are spent on mental health issues during
elderly patients’ office visits. The contents of interactions on
mental health often appeared superficial.
Implications for Policy, Delivery, or Practice: Direct
observation offers information that is unavailable from
traditional data on the actual process and content of care.
Having a visit, by itself, does not guarantee that patients will
receive guideline-concordant mental health services in primary
care settings. As the majority of elderly patients with mental
health problems seek care from primary care physicians,
quality improvement effort should take into account how
mental health care is actually delivered. Incentives should be
aligned with care that provides patient-centered mental health
care.
Primary Funding Source: NIMH, NIA
●Relationship Between Organizational Context and
Penetration of Quality Improvement Interventions: Cases
Studies from Implementing Depression Collaborative Care
Elizabeth Yano, Ph.D., MSPH, JoAnn E. Kirchner, M.D.,
M.P.H., Jacqueline F. Fickel, Ph.D., Louise E. Parker, Ph.D.,
Mona J. Ritchie, MSW, Lisa R. Rubenstein, M.D., MSPH
Presented By: Elizabeth Yano, Ph.D., MSPH, Deputy Director,
Research Service, VA Greater Los Angeles HSR&D Center of
Excellence, 16111 Plummer Street (Mailcode 152), Sepulveda,
CA 91343; Tel: (818) 895-9449; Fax: (818) 895-5838; Email:
elizabeth.yano@va.gov
Research Objective: Capitalizing on its 25-year investment in
health services research, the Veterans Health Administration
(VA) has embarked in a series of research-clinical partnerships
through the Quality Enhancement Research Initiative (QUERI)
to accelerate implementation of effective interventions into
routine care. One of many national QUERI disease targets,
depression is particularly common and disabling, with
national implementation of collaborative care for depression
being one of VA’s top primary care strategic priorities.
Collaborative depression care forges shared care between
primary care providers and mental health specialists through
provider education, informatics-based decision support,
leadership support, and a depression care manager, who
provides telephone assessment of visit-based positive screens
and telephone management and follow-up of depressed
patients. Although substantial evidence demonstrates the
effectiveness of collaborative care for improving depression
management and patient outcomes, little is known about the
factors underlying the intervention penetration. We evaluated
the influences of contextual and organizational characteristics
on the degree of penetration during implementation of
depression collaborative care in a sample of primary care
practices.
Study Design: We combined measures from administrative
data from VA’s national standardized data repository
(location, patient caseload, workload, staffing) with process
evaluation results on penetration (proportion of providers
referring patients to intervention; # consults made, # provider
education sessions) and qualitative data from semi-structured
interviews of VA managers, providers and patients to evaluate
links between organizational context and effectiveness of
implementation in VA primary care practices. Coder dyads
analyzed interview data utlizing a a grounded theory approach.
We evaluated aggregated qualitative and quantitative data
using cross-case analysis.
Population Studied: Six first-generation primary care
practices in three VA networks spanning five states
participated in a depression QI initiative. We interviewed
primary care and mental frontline providers, clinic
administrators, senior and mid-level health care managers,
depression care managers, a small sample of consumers
enrolled in the intervention, and consumer representatives
(n=106).
Principal Findings: From 1-10% of primary care patients were
diagnosed with depression across participating practices. The
speed or extent of penetration was not influenced by primary
care and mental health provider relationships, area
characteristics, such as urban/rural location, or practice size
with the exception of large practices (>13,000 patients), where
penetration was poorest. Initiating an early collaborative care
referral did not predict future referral behavior. Highest
referral rates occurred among practices with the lowest levels
of perceived mental health staffing.
Conclusions: The extent of penetration of an otherwise
effective depression QI intervention varied widely not by area
or practice characteristics but by the extent to which clinics
perceived that MH access was poor because of low perceived
MH staffing levels.
Implications for Policy, Delivery, or Practice: Although the
VA represents an exceptional “laboratory” within which to
translate research into practice given common electronic
medical records, identifiable management structures, and
common policies and procedures, effective penetration may
have less to do with these enablers than local clinic
characteristics and needs.
Primary Funding Source: VA
Call for Papers
Diffusion & Patterns of Medication Use for Mental &
Substance Use Disorders
Chair: Mady Chalk, Treatment Research Institute
Monday, June 26 • 8:30 am – 10:00 am
●Adherence to Antidepressant Medications among Health
Plan Members Diagnosed with Major Depression
Ayse Akincigil, Ph.D., John Bowblis, M.A., Carrie Levin, Ph.D.,
Saira Jan, Pharm.D., Stephen Crystal, Ph.D.
Presented By: Ayse Akincigil, Ph.D., Visiting Assistant
Professor, School of Social Work, Rutgers, The State University
of New Jersey, 536 George Street, New Brunswick, NJ 08901;
Tel: (732) 932-5067; Fax: (732) 932-8592;
Email: aakinci@rci.rutgers.edu
Research Objective: There is a large amount of evidence that
antidepressants are effective in reducing symptoms of
depression and preventing relapse; however, poor adherence
to medication is a major obstacle to effective care. We
describe characteristics of patients at risk for low adherence,
and implications for policy and practice.
Study Design: A retrospective, observational study using
linked medical and pharmacy claims from a large health plan
operating in the Northeast U.S.
Population Studied: 4,546 subjects aged 18 or older,
continuously enrolled in the health plan throughout the study
period with a new episode of major depression who were
started on an antidepressant treatment between January 2003
and January 2005.
Principal Findings: Adherence was measured by refill
persistence using measures adapted from the National
Committee for Quality Assurance’s HEDIS measures for
outpatient depression care. For each patient who initiated
antidepressant (ADP) therapy, an antidepressant medication
possession ratio (MPR) was created using days supplied and
prescription fill dates from pharmacy claims. MPRs were
calculated for both the acute phase of the episode (16 weeks
following the initial diagnosis) and the continuation phase (8
months following the initial diagnosis). Adherence was
defined as a MPR > 0.75. Half of the patients were adherent
in the acute phase and 28% in the continuation phase.
Factors significantly associated with worse adherence in
multivariate analyses, for both the acute and continuation
phases, included residence in a lower-income neighborhood,
male gender, and comorbid alcohol abuse (other substance
abuse was significant in the acute phase). In both phases,
younger members were at greater risk of nonadherence, with
adherence significantly lower for members under age 40.
Adherence was higher for members with six or more non-ADP
medications than for those with only one or two other
medications. Receipt of followup services from a psychiatrist
was associated with better adherence in both phases.
Conclusions: Depression care guidelines emphasize
adequate duration of antidepressant therapy, but many plan
members fall short of these guidelines. Specific demographic
characteristics (e.g., younger age, male gender and residence
in a low income neighborhood) as well as clinical
characteristics (e.g., indications of alcohol abuse) can be used
to predict those at highest risk of nonadherence. The
possibility of “medication crowd-out” among users of multiple
medications has also been suggested, but results of this study
do not support this scenario.
Implications for Policy, Delivery, or Practice: As health
plans seek to improve quality of depression care by improving
adherence to guidelines for antidepressant therapy duration,
particular attention needs to be paid to overcoming barriers
associated with low income and with substance abuse and
medical comorbidity. Men and younger members appear to
be at special risk of nonadherence. A variety of interventions
need to be tested to improve adherence, with special attention
to these higher-risk subgroups. Referral to specialty care in
appropriate cases may be a potential vehicle to improve low
adherence rates associated with depression care in the
primary medical care sector; further research is needed on the
relationship between sector of care and adherence.
Primary Funding Source: NIMH
●The Impact of FDA Regulatory Policy on Depression
Treatment for Children and Adolescents
Susan Busch, Ph.D., Colleen L. Barry, Ph.D., Robert
Rosenheck, M.D., Richard G. Frank, Ph.D.
Presented By: Susan Busch, Ph.D., Assistant Professor,
Health Policy, Yale University, PO Box 208034, New Haven,
CT 06520; Tel: 2037852927; Fax: 2037856287;
Email: susan.busch@yale.edu
Research Objective: In September 2004, an FDA advisory
panel recommended that a black box warning directed at
youth be placed on newer SSRI-class antidepressants in
response to evidence that SSRIs may be associated with
elevated risks of suicidality. The objective of this study is to
examine the impact of FDA regulatory actions on treatment
received by youth with depression.
Study Design: We use outpatient, inpatient and
pharmaceutical claims data from Medstat's Marketscan
database to measure the effects of FDA actions on depression
treatment patterns. We identify youth diagnosed with Major
Depression (ICD codes 296.2, 296.3), and construct episodes
of treatment using CPT codes, NDC codes and dates on
claims. We classify treatment into distinct categories (e.g.,
psychotherapy alone, SSRI alone, combination therapy, no
treatment). We examine treatment patterns before and after
both the original FDA advisory (March 2004) and the FDA
‘black-box’ warning (September 2004). We use multinomial
logit regression to assess the impact of the FDA policy
change.
Population Studied: A national sample of privately insured
youth newly diagnosed with Major Depression (N=6920).
Principal Findings: We find a decline in the use of
antidepressant treatments by children and adolescents after
the FDA warning, and an increase in the share of youth not
receiving effective treatments for depression.
Conclusions: FDA actions led to significant changes in
treatment for depression in children and adolescents.
Implications for Policy, Delivery, or Practice: The FDA
ruling elicited controversy reflecting the fundamental tradeoffs associated with weighing risks against benefits under
conditions of scientific uncertainty (Carpenter, 2004).
Supporters argued that evidence of elevated risks of suicidality
linked to use of antidepressants in youth was sufficiently
serious to warrant informing providers and consumers.
Critics countered that the FDA action would broadly reduce
the use of an effective treatment for depression thereby
producing poorer mental health outcomes (including some
upward pressure on the risk of suicide) in an underserved
population. This research provides evidence of a significant
reduction in the use of antidepressant medications, and an
increase in the share of youth with depression not receiving
effective treatment. In future work, we plan to assess the net
impact of this decline in treatment on suicide attempts.
Primary Funding Source: No Funding
●Psychotropic Medication Diffusion: State-level
differences
Marisa Domino, Ph.D.
Presented By: Marisa Domino, Ph.D., Associate Professor,
Health Policy and Administration, UNC, Campus Box 7411,
Chapel Hill, NC 27599-7411; Tel: (919) 966-3891; Fax: (919)
966-6961; Email: domino@unc.edu
Research Objective: The last decade has witnessed
unprecedented growth in new technologies in mental health
treatment. The availability of new pharmacological agents has
had an enormous impact on the treatment of mental health
disorders, enabling recipients of these medications to
experience relief of many symptoms and improve their levels
of functioning and quality of life. The diffusion of these new
behavioral health technologies, or rate at which these
products have spread through the market, has been very
uneven. Some psychotropic medications, such as Selective
Serotonin Reuptake Inhibitors (SSRIs), now considered first
line treatments for depression, have diffused very quickly,
while others, such as venlafaxine, also a treatment for
depression with equal efficacy have not had much success
developing a substantial market share. In order to advance
models of best practice, it is important to understand the
factors that underlie these varying rates of diffusion.
Differences in adoptions and diffusion rates of psychotropic
medications across insurance settings, geographic regions, or
subpopulations defined by age, gender, or racial or ethic
groups has important implications for the quality of care
received by persons with mental illnesses. The purpose of this
paper is to examine whether states have different rates of
psychotropic drug diffusion in fee-for-service Medicaid
programs and whether those differing rates.
Study Design: Data on all psychotropic medications
reimbursed through fee-for-service Medicaid programs in
almost all states (n=49) in the US were obtained from 19912003. Prescriptions were converted to daily dose units in order
to pool information from medication classes. Two of the
major classes of psychotropic medications, antidepressants
and antipsychotics were examined separately. State-level fixed
effect regressions were run on the dependent variable of daily
dose units, with state-level Medicaid managed care
penetration as the explanatory variable of interest. Diffusion
curves were also modeled using a classic logit framework as
well as with hyperbolic secant function.
Population Studied: Psychotropic medication use
reimbursed through fee-for-service Medicaid programs in
almost all states (n=49) in the US.
Principal Findings: Wide differences were found in diffusion
rates across states. State level characteristics, such as
managed care penetration level, have some ability to predict
differential diffusion rates.
Conclusions: Wide differences in diffusion rates are largely a
puzzle, given the federal (not state) drug approval process.
Differences were noted in diffusion characteristics among
diffusion modeling approaches.
Implications for Policy, Delivery, or Practice: The tools used
by many managed care programs, including prior
authorization and drug formularies may delay the receipt of
treatments and these effects may be spilling over to nonmanaged settings. Further research to examine diffusion
differences is warranted.
Primary Funding Source: NIMH
●Coverage and Management of Medications for Treating
Substance Abuse in Private Health Plans
Sharon Reif, Ph.D., Constance Horgan, ScD, Dominic
Hodgkin, Ph.D., Deborah Garnick, ScD, Elizabeth Levy
Merrick, Ph.D., MSW
Presented By: Sharon Reif, Ph.D., Research Scientist,
Schneider Institute for Health Policy, Brandeis University, 415
South Street, Waltham, MA 02454-9110; Tel: 781-736-3924;
Fax: 781-736-3905; Email: reif@brandeis.edu
Research Objective: Important clinical advances in the
pharmacologic treatment of addiction highlight the need for
studies focused on the role of prescription drugs for
substance abuse treatment. A key development is that
buprenorphine can be prescribed for opioid-dependent
individuals in an office-based setting. At the same time, many
health plans have implemented cost-sharing requirements
and administrative controls to constrain escalating
prescription costs. While more emphasis is placed on officebased medications, the extent of restrictions influencing
availability of these medications to consumers is unknown.
Prescription policies may impact physicians’ inclination to
prescribe and patients' use of these medications. These
policies include formulary coverage exclusions, prior
authorization requirements and placing medications on costsharing tiers with higher copayments. This study reports on
the extent and stringency of private health plans' management
of naltrexone and disulfiram for alcohol dependence,
Suboxone and Subutex for opioid dependence, and
buproprion for tobacco dependence.
Study Design: Survey of commercial health plans in 60 US
market areas regarding administrative and clinical aspects of
behavioral health care delivery in 2003, yielding national
estimates of plan features (N=368, response rate 83%).
Population Studied: Commercial health plans in 60 US
market areas.
Principal Findings: Thirty percent of products excluded
coverage for Subutex and Suboxone, yet only 6% of products
exclude coverage for Revia and naltrexone. Furthermore,
more half of products place the opioid medications on the
highest cost-sharing tier, 41% do so for Revia, and 27% for
disulfiram; generic naltrexone was on lower tiers in almost all
cases. Outpatient methadone maintenance, while not
provided as a prescription benefit, is offered by 65% of
products, providing further access to medication. Disulfiram
is the only medication for substance abuse that is both rarely
excluded from coverage and usually placed on an intermediate
cost-sharing tier. Prior authorization is rarely required for
substance abuse medications, but is used more frequently for
opioid and nicotine medications than for alcohol medications.
Exclusions and tiering vary by contracting arrangements, but
rarely by product type.
Conclusions: While prior studies of substance abuse
medications have examined diffusion and adoption, none
have examined availability of medications to a commercially
insured population. Health plan products are significantly
more likely to employ either coverage exclusion or high costsharing tier placement for substance abuse medications than
they are for antidepressants or antipsychotics. Access to
medication for substance abuse treatment is thus limited
depending on the structure of prescription drug benefits.
Implications for Policy, Delivery, or Practice: There is more
to accessing treatment medications than placement on
formularies. Behavioral health policymakers should consider
access as consisting of two levels. First, inclusion on
formularies is necessary for these medications to be treatment
options at all. Second, most private health plans use tiering.
As medications to treat addictions are often placed on the
higher tiers, financial access becomes an important issue that
may restrict use of medications to treat addictions.
Primary Funding Source: NIAAA
●Factors Associated with Adoption of New Medications in
Substance Abuse Treatment
Cindy Thomas, Ph.D., Sharon Reif, Ph.D., Sayeda Haq, MS,
Alexander Hoyt, RN, MS, Jon Chilingerian, Ph.D., Stanley S.
Wallack, Ph.D.
Presented By: Cindy Thomas, Ph.D., Senior Scientist,
Schneider Institute for Health Policy, Brandeis University, 415
South Street MS035, Waltham, MA 02454; Tel: 781-736-3921;
Email: cthomas@brandeis.edu
Research Objective: Through legislation passed in 2000,
physicians can now prescribe buprenorphine for opioid
addiction treatment. The goal is to increase access to
treatment, and encourage more providers to address the
problem of addiction. Physicians must be certified by
attending a short training course, or must obtain a waiver to
prescribe. However, not all physicians who treat patients with
addictions have sought approval to prescribe buprenorphine.
This survey of addiction treatment specialists and general
psychiatrists identifies factors associated with physicians’
obtaining approval to prescribe buprenorphine, rates of
prescribing, how it is most often used, and barriers to
adoption of this practice.
Study Design: We designed and tested a mail and electronic
survey of psychiatrists and addiction specialists, addressing
the following domains: demographics and practice setting;
market features; patient characteristics; attitudes and practices
towards treatment approaches; organizational roles;
knowledge about buprenorphine and prescribing practices;
reasons for prescribing decisions. Analyses include a
description of the population treating substance abuse;
differences between prescribers and nonprescribers; and
multivariate analyses of factors associated with adoption.
Population Studied: Physicians who are addiction treatment
specialists in four market areas (n=239, 69% response rate)
and a sample of psychiatrists in the same areas (n=224, 55%
response rate). Market areas with high rates of heroin
addiction in the greater metropolitan area, were selected .
These include Boston, Chicago, Los Angeles, and
Miami/Dade.
Principal Findings: 90% of specialists and 13% of general
psychiatrists who currently have patients with addictions have
received approval to prescribe buprenorphine. Although 65%
of specialists prescribe buprenorphine only 4% of general
psychiatrists do so. 18% of psychiatrists had not heard of
buprenorphine. Prescribing differed by market area, with
prescribers significantly more likely (p<.05) to be: male; in
recovery from substance abuse; in group practice; affiliated
with organizations that support use of buprenorphine; work in
a specialty substance abuse facility; and have first heard about
buprenorphine through journals and SAMHSA’s Center for
Substance Abuse Treatment (CSAT). 76% of physicians who
were affiliated with organizations that support use of
buprenorphine prescribe it, and 53% of specialists in
organizations that do not recommend its use prescribe it
anyway. Prescribers most often report using buprenorphine
for maintenance < one year rather than long term. Barriers to
prescribing included: not fitting in with my practice; would
change patient mix undesirably; and prescribing is too
complex.
Conclusions: Although federal agencies have been successful
in training and encouraging specialists to prescribe
buprenorphine, this approach has not been successful in
encouraging general psychiatrists to either use buprenorphine
or treat more addiction patients. The role of organizations in
promoting use of buprenorphine is critical to its adoption.
Implications for Policy, Delivery, or Practice: In order to
encourage adoption of buprenorphine, the impact of
treatment organizations on clinician practices needs to be
incorporated into the educational process. Policies should be
employed to encourage organizations to support
buprenorphine training of their physicians. Further, additional
challenges exist in order to engage general psychiatrists in this
practice and in treating this population.
Primary Funding Source: NIDA
Call for Papers
Multi-System Issues in the Delivery & Costs of
Behavioral Health Care
Chair: Junius Gonzales, Abt Associates, Inc.
Monday, June 26 • 3:45 pm – 5:15 pm
●The Implementation of an Evidence-Based Practice for
Persons with Severe and Persistent Mental Illness: The
Health, Behavioral Health and Criminal Justice Utilization
Patterns and Costs Associated with Assertive Community
Treatment
Gary Cuddeback, Ph.D., Joseph P. Morrissey, Ph.D., Marisa E.
Domino, Ph.D., Edward C. Norton, Ph.D.
Presented By: Gary Cuddeback, Ph.D., Research Fellow, Cecil
G. Sheps Center for Health Services Research, University of
North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd.,
CB#7590, Chapel Hill, NC 27599; Tel: 919-966-0995; Fax: 919966-1634; Email: cuddeback@mail.schsr.unc.edu
Research Objective: Assertive Community Treatment (ACT)
is an evidence-based treatment designed to keep persons with
severe and persistent mental illness out of our psychiatric
hospitals and functioning well in the community. ACT is
expensive and is cost effective for those persons with severe
and persistent mental illness who are the heaviest users of
inpatient psychiatric care, however, the cost effectiveness of
ACT with respect to primary health care and criminal justice
systems has yet to be fully explored. This study examines the
health, behavioral health and criminal justice utilization
patterns and costs of persons with severe and persistent
mental illness who received ACT.
Study Design: A quasi-experimental case-control study design
was used to compare the health, behavioral health and
criminal justice utilization patterns and costs for homeless
persons with co-occurring severe and persistent mental illness
and substance abuse disorders who received ACT (cases) and
those who did not (controls). Propensity scoring was used to
identify control subjects among persons with severe and
persistent mental illness who were not ACT recipients.
Administrative data from inpatient and outpatient county
mental health, state hospital, Medicaid and the local jail
systems were accessed and linked at the person level over a
5.5-year study period.
Population Studied: Persons with severe and persistent
mental illness in King County (Seattle), Washington (N =
2,240).
Principal Findings: Results suggest ACT recipients had lower
inpatient health, behavioral health and state hospital costs
and lower jail costs compared to those who did not receive
ACT. Findings were similar with regard to service utilization in
that ACT recipients had lower inpatient health and behavioral
health service and jail utilization. Further analyses using twopart difference-in-differences models will be used to compare
the differences in health, behavioral health and jail costs and
service utilization patterns among ACT recipients and nonrecipients.
Conclusions: ACT has the potential to reduce the use and
costs of inpatient health and behavioral health and jail
systems for persons with severe and persistent mental illness.
However, ACT is expensive and the burden of cost of
providing ACT is borne by the outpatient mental health
system, whereas the cost savings from ACT are realized by the
inpatient health and behavioral health (local and state
hospitals) and jail systems.
Implications for Policy, Delivery, or Practice: ACT has the
potential to reduce the use of costs of inpatient health and
behavioral health and jail systems; however, it is well
documented that ACT is not available to many persons with
severe and persistent mental illness who could benefit from it.
Health, behavioral health and criminal justice policies should
be aligned such that the burden of the cost of providing ACT
does not reside solely with the outpatient behavioral health
system.
Primary Funding Source: NIMH
●Differential Access to Services for Co-occurring Mental
Health and Substance Abuse Disorders Across Managed
Care and Fee for Service Systems
Roy Gabriel, Ph.D., Bentson H. McFarland, M.D., Brigid G.
Zani, M.S., Lynn E. McCamant, M.S., Kelly J. Vander Ley, Ph.D.
Presented By: Roy Gabriel, Ph.D., Senior Research Associate,
RMC Research Corporation, 522 SW Fifth Ave., Suite 1407,
Portland, OR 97204; Tel: (503) 223-8248; Fax: (503) 223-8399;
Email: rgabriel@rmccorp.com
Research Objective: This study examines rates of access to
substance abuse services for Medicaid adults already receiving
mental health treatment services; and access to mental health
services for Medicaid adults already receiving substance abuse
treatment services. These access rates are compared across
managed care and fee for service systems in 10 states and key
predictors of receipt of services across both substance abuse
and mental health service systems are identified using the
health service utilization framework developed by Anderson et
al (1979).
Study Design: The current study is a secondary analysis of
data from a family of 10 studies funded by the Substance
Abuse and Mental Health Services Administration (SAMHSA)
from 1996-2000. These studies were designed to assess the
effects of managed care on the use, cost and outcomes of
behavioral health treatment services. Interview protocols
included standardized assessment instruments such as the
Addiction Severity Index (ASI), the SF-12 and the Beck
Depression Inventory. Medicaid adults entering treatment
were assessed within two weeks of intake and six months
later.
Population Studied: N=2424 Medicaid adults completed
intake and followup assessments in the SA services
population; and N=2318 Medicaid adults completed these
assessments in the MH service sample. In general, SA
treatment participants were more likely to be male (60%) and
younger (ave. 38 years) than their MH treatment counterparts.
However, adults in each system (SA, MH) were equally likely
to have received treatment in the other system (MH, SA) in
their lifetimes.
Principal Findings: Approximately 15% of adults in both MH
and SA treatment systems received services in the other
system during the time period under study. In the MH system,
access to SA treatment was more likely in a fee for service
system; while, in the SA system, access to MH services was
more likely under managed care. Severity of alcohol and drug
problems (as measured by the ASI) for MH treatment
recipients, and psychiatric problems (ASI) for SA treatment
recipients were strong predictors of cross-system service
access. However, in the SA system, patients who were White,
female and older were more likely to receive MH treatment
services; and in the MH sample, patients who were younger
were more likely to receive SA treatment services.
Conclusions: While rates of access of SA and MH treatment
across these systems are roughly equivalent, there are
significant differences in this access for adults in managed
care vs. fee for service financing systems; and receipt of
services are influenced by different patient characteristics in
the two systems.
Implications for Policy, Delivery, or Practice: Co-occurring
disorders are increasingly recognized as the expectation,
rather than the exception, for adults in either mental health or
substance abuse treatment systems. The current study
suggests that clinical criteria for identifying need for services
are key considerations in both systems. However,
demographic characteristics of dubious relation to clinical
need appear to be operating in each system, suggesting that
age, gender and racial/ethnic disparities likely exist in access
to services for co-occurring mental health and substance
abuse disorders.
Primary Funding Source: RWJF, Substance Abuse and
Mental Health Services Administration
●Impact of Foster Care Placement Change on Mental
Health Treatment Continuity
Michelle Garrison, M.P.H., Maureen Marcenko, Ph.D., Noel
Weiss, M.D., DPH, Dimitri Christakis, M.D., M.P.H., Ann
Vander Stoep, Ph.D.
Presented By: Michelle Garrison, M.P.H., Doctoral Candidate,
Child Health Institute, University of Washington, 6200 NE
74th St, Suite 210, Seattle, WA 98115; Tel: 206-616-1203; Fax:
206-616-4623; Email: garrison@u.washington.edu
Research Objective: Foster care youth are at increased risk
for behavioral and affective disorders, and they are also more
likely to utilize mental health services than the general
population. Continuity of mental health treatment is
assoicated with better outcomes, but foster care placement
changes can present barriers to maintaining treatment. This
study sought to determine whether change in foster care
placement is temporally associated with subsequent
disruption in ongoing mental health treatment.
Study Design: We conducted a case-crossover study,
comparing within the same individual the occurrence of foster
care placement changes between months with and without
treatment disruption over the course of the study year.
Treatment disruption was defined as having a month without
outpatient counseling immediately after having at least three
consecutive months with at least one non-emergent
counseling session each month. Matched conditional logistic
regression models were fitted, and were adjusted for potential
time-varying confounding factors, including current placement
type and the number of placement changes within 12 months
prior. A sub-analysis was also performed to examine whether
the restrictiveness of the placement type had an impact on
treatment disruption – for example, a move from a foster
home to a residential treatment setting would be an increase
in placement restrictiveness.
Population Studied: The study sample was drawn from the
6,153 youth ages 5 to 18 years who spent at least 3 months in
foster care in Washington State during fiscal year 1999. The
sample of interest in this analysis was youth from the dataset
who received ongoing mental health treatment. The study
data were derived from administrative databases and included
foster care history, Medicaid claims, and mental health
utilization.
Principal Findings: There were 1906 youth in the sample who
received counseling for at least 3 continuous months; of
those, 1054 (55%) had a disruption in counseling and 1109
(58%) experienced a foster care placement change during the
study year. A foster care placement change was significantly
associated with a subsequent disruption in counseling (OR =
1.56, 95% CI = 1.21 to 2.01). In the sub-analysis, risk of
treatment disruption was elevated in children who moved to a
less restrictive placement compared to those experiencing no
placement change (OR = 2.14, 95%CI = 1.14 to 4.02), as were
moves within the same level of restrictiveness (OR = 1.57, 95%
CI = 1.17 to 2.11). Foster care placement changes to more
restrictive settings were not significantly associated with
disruption in counseling (OR = 1.26, 95% CI = 0.80 – 1.99).
Conclusions: Youth are at an increased risk for a disruption in
ongoing counseling following a foster care placement change.
This disruption in mental health treatment may partially
mediate the increase in behavioral and affective symptoms
observed following placement changes in prior research.
Implications for Policy, Delivery, or Practice: Although it
may be challenging in practice to maintain mental health
treatment continuity across foster care placement changes, it
will be important to explore whether increased efforts in this
regard can benefit foster care youth.
Primary Funding Source: Gatzert Child Welfare Fellowship
●Access, Utilization, and Cost of Integrated vs. Referral
Substance Abuse Care: Results from the PRISM-E Study
James Maxwell, Ph.D., Tanaz Petigara, Karen Cheal, M.P.H.,
Marisa Domino, Ph.D., Eugenie Coakley, M.P.H., Sue Levkoff,
Sc.D.
Presented By: James Maxwell, Ph.D., Director of Health Policy
and Management Research, Health Services, JSI Research and
Training Institute, 44 Farnsworth Street, Boston, MA 02110;
Tel: 617-482-9485; Fax: 617-482-0617; Email: maxwell@jsi.com
Research Objective: To compare engagement, utilization,
and costs of substance abuse care associated with two
PRISM-E intervention models—an integrated care model
where the patient is treated by a behavioral health practitioner
co-located in a primary care setting and an enhanced referral
model where the patient is referred to a specialty provider;
services are enhanced through scheduling and transportation
support.
Study Design: The Primary Care Research in Substance
Abuse and Mental health for the Elderly (PRISM-E) study
conducted screening in primary care clinics and defined a
non-treatment seeking patient population of at-risk drinkers,
with and without problem drinking. At-risk drinking – which
increases the probability of adverse drinking-related
consequences was defined as drinking twice the NIAAA
recommended limit. Problem drinking – in which individuals
may have already experienced adverse physical, mental, or
social consequences as a result of their drinking- was defined
as having a SMAST-G score of >=3. Patients who screened
positive for at-risk drinking were randomized to either a three
session, brief alcohol intervention (BAI) in their primary care
setting or referred to enhanced specialty substance abuse
and/or mental health settings. Engagement (at least one faceto-face visit with MH/SA provider), utilization (number of SA
visits), and costs (outpatient and inpatient) for substance
abuse care were examined in this intent-to-treat analysis, and
compared between the integrated and enhanced referral arms
of the study. Analyses were conducted on the full cohort of atrisk drinkers, as well as stratified by at-risk drinkers with and
without problem drinking.
Population Studied: Older adults,aged 65 and over, who
assessed positively for at-risk drinking with complete data.
Principal Findings: For the full cohort of at-risk drinkers, IC
patients had higher engagement (56 vs. 34 percent) and
average number of SA visits (1.13 vs. 0.61 visits) than ESR
patients. Within IC, at-risk drinkers with and without problem
drinking had similar engagement rates (60 vs. 50 percent,
p=0.19) but at-risk drinkers with problem drinking had
significantly higher utilization rates (37 vs. 24 percent;
p=0.005). Within ESR, problem drinkers had significantly
higher engagement (44 vs. 25 percent; p=0.05) and utilization
rates (21 vs. 8 percent; p=0.006) compared to at-risk drinkers
without problem drinking. We also found a positive
association between drinking severity and co-morbid mental
health disorders. Drinkers with SMAST-G >=3 were more than
twice as likely to have a mental health co-morbidity. Average
per person costs for outpatient substance care was higher in
IC than ESR, possibly reflecting higher overall engagement
and utilization rates in the IC model. Having had a BAI
increased costs in both VA and non-VA settings, however, this
cost increase was lower than other alternatives. Average
hospital costs were higher for ESR than IC patients. Hospital
costs increased significantly with increases in SMAST-G score.
For those patients with hospital stays only, average hospital
expenditures increased by $1752 for every one point increase
in SMAST-G score.
Conclusions: We identified three groups of drinkers—at-risk
drinkers without problem drinking, at-risk drinkers with
problem drinking, and at-risk drinkers with co-morbid
depression and anxiety. Each of these groups has distinct
needs and costs associated with their care.
Implications for Policy, Delivery, or Practice: The needs of
each of these groups must be considered when designing
alcohol use interventions in primary care. For more complex
patients, a specialty SA setting may be more appropriate, but
the BAI has potential as a tool to introduce them into
treatment. The report provides recommendations for
improving access and care for these groups.
Primary Funding Source: CSAT
●The Effect of Reductions in Psychiatric Beds on Jail Use
by Severely Mentally Ill People
Jangho Yoon, MSPH, Marisa E. Domino, Ph.D., Joseph
Morrissey, Ph.D., Edward C. Norton, Ph.D.
Presented By: Jangho Yoon, MSPH, Ph.D. student, Health
Policy and Administration, The University of North Carolina at
Chapel Hill, 10350 Crestgate Terrace Apt #305, Raleigh, NC
27617; Tel: (919)757-2886; Email: jang@unc.edu
Research Objective: The U.S. mental health system has
witnessed a substantial decrease in the number of psychiatric
beds over the past several decades. Many have investigated
the implications of this trend and have become more
concerned about the overlaps between the mental health and
criminal justice systems, suggesting the decrease in
psychiatric beds as a contributing factor for the overrepresentation of mentally ill people in jail and also that
having mentally ill offenders in jail is expensive. However, no
previous efforts have been made to understand the
relationship between the reduction in the number of
psychiatric beds and jail incarceration by the mentally ill
people. This study attempts to address this question by
examining the extent to which a decrease in psychiatric beds is
associated with the likelihood that severely mentally ill people
are found in jail. It was hypothesized that a group of
individuals with severe and persistent mental illness (SPMI)
and substance abuse disorders (SA) was mostly likely affected
by the change in the capacity of inpatient psychiatric services,
while a group of individuals without any mental illness should
not be affected.
Study Design: Using a sample from three systems in King
County, Washington – jail, the public mental health system,
and Medicaid – from 1993 to 1998, 2.6 million individualmonth observations on 41,465 persons over 66 months were
created. The sample was separated into four groups:
individuals with SPMI and SA; individuals with SPMI but
without SA; individuals with mild mental illness; and
individuals without mental illness. Maximum likelihood logit
models of a monthly jail use dummy on the pooled data set
were estimated for each of the subgroups.
Population Studied: Residents in King County, Washington,
aged 18-64.
Principal Findings: The number of psychiatric beds in King
County decreased by 236 (15 percent) over the study period
and was negatively associated with the likelihood that
individuals with SPMI and SA were incarcerated into jail. 1.86
percent of the individual-month observations for the SPMI-SA
group had jail use. On average, the decrease of the 236 beds
was associated with an increase in the probability that persons
with SPMI and SA were incarcerated in jail by 0.25 percentage
points a month. No significant effects were found on other
three groups.
Conclusions: There appears to be a relationship between a
decrease in psychiatric beds and jail use by individuals with
SPMI and SA. Considering that less than two percent of the
observations for the SPMI-SA group had jail use, the
magnitude of the effect is substantial. Despite the limitations
of the study, the findings may provide evidence to the concern
that the elimination of psychiatric beds would increase jail
incarceration.
Implications for Policy, Delivery, or Practice: Psychiatric
beds continue to decline. Policymakers should be aware that
reductions in the number of psychiatric beds could have
unintended consequences to society. Societal costs
attributable to decreased psychiatric beds may exceed the
benefits from reduced psychiatric beds.
Primary Funding Source: NIMH
Call for Papers
Benefit Structure, Service Utilization, and Costs of
Behavioral Health Care
Chair: Constance Horgan, Brandeis University
Tuesday, June 27 • 8:45 am – 10:15 am
●Effects of State Parity Laws on the Family Financial
Burden of Children with Mental Health Care Needs
Colleen L. Barry, Ph.D., Susan H. Busch, Ph.D.
Presented By: Colleen L. Barry, Ph.D., Assistant Professor,
Department of Epidemiology and Public Health, Yale School
of Medicine, 60 College Street, New Haven, CT 06520; Tel:
(203) 785-4956; Email: colleen.barry@yale.edu
Research Objective: To study the impact of state parity laws
on children in need of mental health services.
Study Design: We examine whether state parity laws: (1)
reduce the financial burden on families of children with
mental health conditions and (2) increase the probability that
these children receive needed mental health care. We use
instrumental variable estimation controlling for detailed
information on a child’s health and functional impairment.
We compare those in parity and non-parity states and those
needing mental health care with other children with special
health care needs.
Population Studied: Privately insured families in the 2000
SLAITS National Survey of Children with Special Health Care
Needs (N=38,856).
Principal Findings: Multivariate regression results indicate
that living in a parity state significantly reduced the financial
burden on families of children with mental health care needs.
Specifically, we detect significantly lower out-of-pocket health
care spending among families with children needing mental
health care living in parity states compared with those in nonparity states. Families with children needing mental health
care in parity states were also more likely to view these out-ofpocket charges as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly
lowered the likelihood of a family reporting that a child’s
health needs caused financial problems. The likelihood of
reports that additional income was needed to finance a child’s
care was also lower among families with mentally ill children
living in parity states. However, we detect no significant
difference among residents of parity and non-parity states in
receipt of needed mental health care.
Conclusions: These results indicate that state parity laws are
providing important economic benefits to families of mentally
ill children undetected in prior research.
Implications for Policy, Delivery, or Practice: The intent of
parity laws is to improve equity in private insurance coverage
for mental health care. These findings provide evidence of the
beneficial effects of state parity laws on financial risk
spreading with no detectable differences in receipt of care.
Understanding the policy effects of mental health benefit
regulation on children is valuable from a societal perspective.
A unique characteristic of mental health disorders is that they
often emerge in childhood and young adulthood, and can be
highly disruptive from an educational and professional
standpoint. If parity policies lower the financial burden to
accessing mental health care for individuals at younger ages,
they may have beneficial indirect effects on educational
attainment and long-term earning potential.
Primary Funding Source: RWJF, HCFO
●Putting Providers At-Risk: How Strong are Incentives for
Upcoding and Undertreating?
Marisa Domino, Ph.D., Edward C. Norton, Ph.D., Gary
Cuddeback, Ph.D., Joseph Morrissey, Ph.D.
Presented By: Marisa Domino, Ph.D., Associate Professor,
Health Policy and Administration, UNC, Campus Box 7411,
Chapel Hill, NC 27599-7411; Tel: (919) 966-3891; Fax: (919)
966-6961; Email: domino@unc.edu
Research Objective: Capitated payments to providers change
incentives for treatment. Certain forms of capitated payments,
such as case-rate payments, create additional incentives to
change both diagnosis and treatment patterns that may differ
from pure capitated models. Research has shown a link
between the use of case-rate payments and a large (25%)
decrease in the use of mental health services over fee-forservice alternatives and the size of the case-rate payment has
been shown to affect the level of service use. However, the
level of case-rate payment may also affect the assignment of
the severity level, which may have independent effects on
services use and which has not been previously studied. The
purpose of this study is to examine the effect that changes in
case-rate payments used to pay for publicly funded mental
health care have on severity determination and service use.
Study Design: This study takes advantage of a series of
changes in case-rate payments that occurred over a 3-year
period in King County, Washington after the implementation
of such a system in April 1995. We use an ordered logit model
on individual-level data to examine how changes in tiered
payments affect the probability that an individual is classified
in one of six severity categories during their first month in the
capitated program. We also examine count data models for
each severity category on the number of services received per
month as a function of the monthly case-rate payment, using
robust standard errors clustered for repeated observations on
individuals. Separate analyses were conducted on individuals
with service-related diagnoses of severe mental illness.
Population Studied: Individuals receiving publicly-funded
mental health services in King County, WA through the caserate payment program.
Principal Findings: Increases in case-rate payment both
increase the probability of classifying individuals at higher
severity levels and increase the number of services used in
four of the six severity categories. A one dollar increase in the
daily case-rate is associated with between 0.12 and 0.46 more
mental health visits per month. Because those with severe
mental illness comprise the majority of individuals in the
tiered system, results were almost identical for the severely
mentally ill.
Conclusions: Provider payment mechanisms have the
potential to substantially influence treatments received. In
addition, assessment of severity by at-risk providers has the
same incentive problems noted decades earlier in the
Medicare DRG literature.
Implications for Policy, Delivery, or Practice: These
estimates add to the literature on provider payments for
mental health services. Further research is required to
examine the welfare implications of the changes in treatment
rates as a function of the capitated payment rates.
Primary Funding Source: NIMH
●Intensive Substance Abuse Services: Who Continues in
Subsequent Treatment?
Kalyani Gopalan, MS, M.H.A., Bradley D. Stein, M.D., Ph.D,
Jane N. Kogan, Ph.D, Wesley Thompson, Ph.D, Mark Sorbero,
MS
Presented By: Kalyani Gopalan, MS MHA, Analyst, Research,
Evaluation, and Outcomes, Community Care Behavioral
Health Organization, One Chatham Center, 112 Washington
Place, Pittsburgh, PA 15219; Tel: (412) 246-5198; Fax: (412) 5869057; Email: gopalank@upmc.edu
Research Objective: Individuals being treated for substance
abuse (SA) disorders have better clinical outcomes if they are
engaged in formal SA treatment for an adequate period of
time (NIDA, 1999). We examined predictors of SA treatment
discontinuation for publicly insured individuals participating in
a new episode of intensive SA treatment.
Study Design: Secondary claims and administrative data were
examined from a large Managed Behavioral Health
Organization. Multivariate survival analysis and logistic
regression using available predictor variables (gender, age,
race, clinical diagnoses, and category of service) were
conducted to examine probability of follow up of care and
predictors of time until treatment discontinuation, defined as
a 30 day service free period.
Population Studied: 5103 Medicaid insured individuals age
18-64, residing in a Mid-Atlantic urban area who participated
in a new episode of intensive SA treatment during 2003-2004.
Principal Findings: Following intensive SA treatment, 28% of
individuals received no subsequent formal SA care. Rates of
no subsequent care were higher for individuals whose index
episode of care was partial hospitalization (32%, n=533) than
those receiving detoxification (29%, n=481) or residential
treatment (23%, n=407). A multivariate logistic regression
analysis controlling for race and age found that females (OR:
1.54 CI 1.34 to 1.78) and individuals with co-occurring mental
health disorder (OR: 1.88 CI 1.57 to 2.25) were more likely to
receive subsequent care. Individuals whose index episode was
detoxification (OR: 1.35 CI 1.15 to 1.58) or residential treatment
services (OR: 1.53 CI 1.30 to 1.80) were more likely to have
subsequent care. Of those having at least one follow-up visit,
the median (Q1-Q3) duration of treatment before
discontinuation was 57 days (30-135). For individuals whose
index episode was Partial Hospitalization it was 67 (30-153)
and for detoxification and residential services, 50 (30-120) and
58 (32-139) respectively. In a multivariate survival analysis
predicting treatment discontinuation among individuals
receiving any subsequent SA treatment, controlling for race
and age, females (Hazard Ratio: 0.871 [95%CI 0.81 to 0.94]);
individuals whose index episode was partial hospitalization
(Hazard Ratio: 0.9 [95%CI 0.84 to 0.97]), and individuals with
a co-occurring mental health disorder (Hazard Ratio: 0.77
[95%CI 0.70 to 0.83]) continued in treatment longer than
other individuals.
Conclusions: Approximately 30% of individuals receiving
intensive SA treatment did not receive subsequent, less
intensive formal treatment. Among individuals receiving
subsequent care, many individuals were not engaged in formal
SA care through the recommended 90 days. Males and
individuals without comorbid mental health disorders are at
greater risk for no subsequent care and for earlier
discontinuation of formal follow-up care.
Implications for Policy, Delivery, or Practice: Efforts must
be made to increase rates of any follow up care after intensive
SA treatment and enhance retention of individuals receiving
intensive SA treatment. Targeted efforts should be focused on
the populations at greatest risk of no follow up or early
discontinuation.
Primary Funding Source: NIMH, grant # 030915/MHIRC
●The Effect Of Eliminating Medicaid Coverage For Mental
Health And Substance Abuse Treatment Services On
Enrollee Utilization and Expenditures
K. John McConnell, Ph.D., Neal Wallace, Ph.D., Charles A.
Gallia, Ph.D., Jeanene A. Smith, M.D., M.P.H.
Presented By: K. John McConnell, Ph.D., Assistant Professor,
Emergency Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Park Rd., Mail Code CR-114, Portland,
OR 97239; Tel: (503) 494-1989; Fax: (503) 494-4640; Email:
mcconnjo@ohsu.edu
Research Objective: While many states are contemplating
cuts in their Medicaid programs, it is unclear what effect cuts
in the coverage of specific benefits might have on cost and
utilization. Recent experience in Oregon offers an opportunity
to assess the effect of the elimination of specific benefits;
cutbacks in the Oregon Medicaid program in 2003 included
the elimination of coverage for treatment for addiction
disorders and mental illness for certain populations. The
objective of this study was to assess the impact of the
elimination of these benefit packages on utilization and costs
of other services.
Study Design: This retrospective cohort study used Medicaid
claims data to analyze changes in enrollees’ per-member permonth (PMPM) expenditures. We used the method of
“difference-in-differences,” comparing changes in
expenditures by enrollees who lost benefits to a comparable
group of enrollees who did not lose benefits. We selected 3
groups to analyze: (A) users of methadone treatment services;
(B) users of other chemical dependency treatment services;
and (C) users of outpatient mental health services. To control
for secular changes unrelated to the benefit elimination, we
used a control group (D) of individuals with no record of
using any of the eliminated benefits. Users of mental health
and substance abuse treatment services (groups A, B, and C)
were matched to the control group (D) using the propensity
score and local linear regression matching.
Population Studied: We selected individuals who were
enrolled for at least 6 months prior to and following the
elimination of benefits. We analyzed claims for 373 methadone
users (group A), 1041 users of other addiction services (group
B), 2308 users of outpatient mental health services (group C),
matching them to 6245 members of group D, Medicaid
enrollees who did not use any of the eliminated benefits.
Principal Findings: Compared to the control group, expenses
tended to increase among all groups who lost benefits.
However, individuals who lost methadone treatment showed
the most significant and substantial increases, with increases
in PMPM expenditures of $67.40 (95% CI $7.03, $139.44).
Increasing expenditures appeared to be driven by in part by
higher utilization of the emergency department, with PMPM
ED visits increasing by 0.08 (95% CI 0.02, 0.17) and PMPM
ED expenditures $17.64 (95% CI $6.82, $50.06), and possibly
by higher inpatient admissions, with inpatient expenditures
increasing by $51.23 (95% CI -$11.60, $125.09).
Conclusions: Elimination of substance abuse treatment for
methadone users led to significant and substantial increases
in PMPM expenditures. The effect was less pronounced for
the elimination of mental health and other chemical
dependency treatment services.
Implications for Policy, Delivery, or Practice: Elimination of
the coverage of methadone treatment for Medicaid enrollees
apparently raises total PMPM expenditures for these
individuals, and therefore is not advised as a cost-control
mechanism.
Primary Funding Source: RWJF
●Mental Healthcare Utilization as Adolescents Become
Young Adults
Jennifer Yu, Sc.D., Jane Burns, Ph.D., Sally Adams, Ph.D., Jane
Park, M.P.H., Charles E. Irwin, Jr., M.D., Claire Brindis, Dr.P.H.
Presented By: Jennifer Yu, Sc.D., Research Fellow, Institute
for Health Policy Studies, University of California, San
Francisco, 3333 California St., Ste. 265, San Francisco, CA
94143-0936; Tel: (415)514-0244; Fax: (415)476-0705;
Email: Jennifer.Yu@ucsf.edu
Research Objective: Despite parallels in mental health needs
among adolescents and young adults, there is currently a
paucity of evidence regarding utilization of mental healthcare
as adolescents transition into young adulthood. Using a
prospective study sample, this paper addresses this gap in the
literature by: 1) comparing rates of mental health service use
between adolescents and young adults, 2) determining
longitudinal predictors of mental healthcare among young
adults, and 3) examining reasons for foregone care among
those with mental health needs in young adulthood.
Study Design: Secondary data analysis was conducted using
the National Longitudinal Study of Adolescent Health. Data
were derived from an initial school-based survey of
adolescents with a follow-up survey conducted seven years
later. The analyses consisted of descriptive univariate analyses
as well as multivariate logistic regression models in which
adolescent and young adult variables predicted mental health
service use in young adulthood.
Population Studied: The study population consisted of a
nationally representative sample of U.S. adolescents. The
mean age was 15.8 years during the initial survey and 21.8
years at follow-up during young adulthood.
Principal Findings: Among individuals experiencing
depression, fewer young adults than adolescents reported
receiving mental healthcare (15% vs. 21%). When accounting
for depression and suicidality, female gender (OR=1.69, 95%
CI: 1.25-2.29), high maternal education (OR=1.79, 95% CI:
1.08-2.98), school attendance (OR=1.48, 95% CI: 1.09-2.01),
and receipt of routine physical exams (OR=1.47, 95% CI: 1.111.96) were significantly predictive of mental health service
utilization among young adults. Black young adults were
significantly less likely to use services compared to whites
(OR=0.56, 95% CI: 0.35-0.89). 4% of young adults reported
foregone healthcare in the past year, despite self-reported
mental health needs. Inability to pay, belief that the problem
would go away, and lack of time were commonly cited reasons
for foregone healthcare in general. However, concerns
regarding physician’s care (i.e. fear of what the doctor would
say/do, and belief that the doctor would be unable to help)
were more frequently mentioned by those who acknowledged
a need for mental health services.
Conclusions: Although it is commonly understood that high
rates of unmet mental health needs exist in adolescence, this
paper is one of the first to suggest that rates of unmet mental
health needs are greater among young adults, using a largescale, nationally representative study sample. Furthermore,
this paper indicates specific predictors of mental health
service use for young adults, as well as self-reported reasons
given for foregone mental health care.
Implications for Policy, Delivery, or Practice: Findings such
as increased mental health service use among those receiving
routine physical exams as well as reported concerns of
physician care point to possible areas of intervention within
the pediatric and general medical community. Recognizing
factors that may contribute to unmet needs and foregone care
is the first step to improving accessibility and willingness to
receive mental health services in this unique population.
Primary Funding Source: AHRQ
Related Posters
Behavioral Health
Poster Session B
Monday, June 26 • 5:30 pm – 7:00 pm
●Overcoming Barriers to Guideline-Consistent Depression
Care: The Significance of Age
Akincigil Ayse, Ph.D., Stephen Crystal, Ph.D., John Bowblis,
M.A., Carrie Levin, Ph.D., Saira Jan, Pharm.D.
Presented By: Akincigil Ayse, Ph.D., Visiting Assistant
Professor, School of Social Work, Rutgers, The State University
of New Jersey, 536 George Street, New Brunswick, NJ 08901;
Tel: (732) 932-5067; Fax: (732) 932-8592; Email:
aakinci@rci.rutgers.edu
Research Objective: The disease burden of depression ranks
high among all medical conditions, and is associated with
worse outcomes for many comorbid illnesses. In response,
there has been increased attention to the need to improve
depression care, including development of guidelines and
quality measures. Rates of depression identification and
treatment have increased, but studies indicate much need for
improvement in aspects of treatment quality, such as
measures of adequate treatment duration that have been
operationalized in HEDIS depression care quality measures.
To develop effective intervention strategies and target them to
those at greatest risk, better understanding of the predictors of
inadequate treatment and the barriers to more effective care is
needed. In particular, the role of patient age needs to be
better understood, as patients of different ages may face
differing barriers requiring different intervention strategies.
Study Design: To address this question, we examined
adherence to HEDIS guidelines for adequate duration of acute
phase depression care using linked medical and pharmacy
claims from a large health plan operating in the Northeast
U.S., examining the role of various demographic,
socioeconomic, and clinical factors in separate models for
respondents aged 18-39, 40-59, and 60+.
Population Studied: 4,546 members aged 18 or older
continuously enrolled in the health plan throughout the study
period with a new episode of major depression who were
started on an antidepressant treatment between January 2003
and January 2005.
Principal Findings: Rates of adequate treatment duration
increased with age, ranging from 42% in the group aged 18-39
to 59% in the group over age 60. For the 18-39 year old age
group, multivariate modeling indicated that male gender,
residence in a low-income neighborhood, presence of a
substance abuse diagnosis (other than alcohol use), and
followup by a mental health specialist were among the factors
associated with significantly lower rates of treatment
adequacy, while none of these factors was associated with
treatment adequacy in the 60+ group. Conversely, for
members over age 60, cardiovascular comorbidity was
significantly associated with worse guideline adherence, while
this was not the case in the younger group. Members under
age 40 receiving few other (non-ADP) medications (perhaps
reflecting less involvement in the health care system) were
less likely to receive guideline-adherent care than others, while
this was not the case for those over age 60. Patterns in the
middle age group (40-59) were generally intermediate
between those in the youngest and oldest groups.
Conclusions: Predictors of adequacy of treatment duration
vary considerably by age.
Implications for Policy, Delivery, or Practice: Results
suggest that the barriers that need to be overcome, in order to
improve the quality of depression care, differ for members of
different ages, and that hence there is a need to tailor
intervention strategies to members of different ages. For
younger members, addressing socioeconomic and substance
abuse factors and disengagement with the healthcare system
may be of particular importance, while for older members,
addressing medical comorbidities may be especially
important, through strategies such as incorporating
depression care into chronic disease state management
programs.
Primary Funding Source: NIMH
●Racial Differences in Jail-Based Treatment for Mentally Ill
Detainees
Nadine Barrett, M.A., M.S., Ph.D., Marisa E. Domino, Ph.D,
Gary S. Cuddeback, M.S.W., Ph.D, Joseph P. Morrissey, Ph.D
Presented By: Nadine Barrett, M.A., M.S., Ph.D., Postdoctoral
Fellow, Cecil G. Sheps Center for Health Services Research,
University of North Carolina at Chapel Hill, 725 Martin Luther
King Jr. Blvd., CB #7590, Chapel Hill, NC 27599-7590; Tel:
(919) 843-6103; Fax: (919) 966-1634; Email:
NBarrett@schsr.unc.edu
Research Objective: Current research suggests disparities
exist for minority populations in access and use of
community-based mental health services. Do these disparities
carry-over to mentally ill detainees in jail? Today, more than
one million persons with severe mental illness are admitted to
US jails each year. In addition, a disproportionate number of
blacks are entering the criminal justice system, many living
with some degree of mental illness. This study examines the
extent to which racial differences exist with regard to jail
mental health service use among detainees.
Study Design: This presentation addresses these issues with
data over a five-year (1993-98) time period from King County
(Seattle), WA. A quasi-experimental design is used to compare
the jail behavioral health experiences – utilization and costs –
among white and black jail detainees with severe and
persistent mental illness. Two-part models were used to
determine the probability of receipt of services (logistic
regression) and to gain estimates of the intensity of use
(multiple regression) among these two groups.
Population Studied: Jail detainees with severe and persistent
mental illness (N = 4,888) in the King County (Seattle), WA jail
Principal Findings: Among jail detainees with severe and
persistent mental illness, 66% were white and 29% were
black. Within this population, 67% of white detainees received
some behavioral health care during their jail stay compared to
only 37% of black detainees (p< .001). On average, white
detainees had significantly higher jail behavioral health care
expenditures (M = $4,658, SD = $11,906) compared to black
detainees with severe and persistent mental illness (M =
$3,421, SD = $13,023, p < .001). However, among those who
received at least some behavioral health care, more was spent
on black detainees with severe and persistent mental illness
(M = $11,243, SD = $21,411, Mdn = $2,096) compared to their
white counterparts (M = $ 6,977, SD = $14,006, Mdn =
$1,452, p < .001).
Conclusions: These findings suggest that black jail detainees
with severe and persistent mental illness are less likely to
receive behavioral health care; however, among detainees with
severe and persistent mental illness who receive care, more is
spent on jail behavioral health care for black detainees
compared to white detainees.
Implications for Policy, Delivery, or Practice: The current
analyses begins to address the issue of racial disparities in the
delivery of jail behavioral health care; however, these findings
are silent with respect to determining whether the differences
in access to jail behavioral health care services are true
disparities. For example, we are unable to conclude whether
these differences can be attributed to the behavior of
correctional administrators or to jail detainees. Further
research will expand the analyses to consider co-occurring
substance abuse, gender, insurance status, and jail-based vs.
external diagnoses. Jails are a public health outpost and
developing effective interventions for detainees that are fair
and equitable may increase continuity of care with community
services and reduce future detentions.
Primary Funding Source: NIMH
●Findings from the Evidence Report on the Mangement of
Eating Disorders
Nancy Berkman, Ph.D., MLIR, Cynthia M. Bulik, Ph.D.,
Kathleen N. Lohr, Ph.D., Adrienne Rooks, BA
Presented By: Nancy Berkman, Ph.D., MLIR, Health Policy
Analyst, Health, Social, and Economics Research, RTI
International, 3040 Cornwallis Road, PO Box 12194, RTP, NC
27709-2194; Tel: 919.541.8773; Fax: 919.990.8454; Email:
berkman@rti.org
Research Objective: We systematically reviewed the evidence
on outcomes and efficacy of treatment associated with
anorexia nervosa (AN), bulimia nervosa (BN) and binge
eating disorder (BED). We also examined harms associated
with treatment, factors associated with treatment efficacy, and
whether treatment and outcomes for these conditions differ by
sex, age, race, ethnicity, or cultural group.
Study Design: We included studies published from 1980 to
the present, written in all languages. We searched
MEDLINE®, the Cochrane Collaboration libraries and other
sources. We identified 30 treatment studies for AN, 47 for BN,
25 for BED, and 34 outcome studies for AN, 13 for BN, 7
addressing both AN and BN, and 3 for BED.
Population Studied: Studies include populations diagnosed
primarily with AN, BN or BED, aged 10 years and older, that
report on eating, psychiatric/psychological, and/or biomarker
measure outcomes. Studies were conducted in many nations
including the US, the United Kingdom, Germany, New
Zealand and Japan.
Principal Findings: Factors associated with poorer outcomes
in AN were higher levels of depression and compulsivity;
increased mortality was associated with concurrent alcohol
and substance use disorders. Only depression was
consistently associated with poorer outcomes in BN. BN was
not associated with an increased risk of mortality. Because of
sparse data, we could reach no conclusions concerning BED
outcomes.
For treatment of AN, the literature on medications was
sparse and inconclusive. No studies combining medication
with behavioral interventions met inclusion criteria. Forms of
family therapy are efficacious in treating adolescents and
cognitive behavioral therapy (CBT) may reduce relapse risk for
adults after weight restoration. In BN, fluoxetine (60 mg/d)
appears to be efficacious in reducing binge eating and purging
and associated psychological features in the short term. CBT
is efficacious in reducing core behavioral symptoms and
psychological features in both the short and long term. How
best to treat individuals who do not respond to CBT or
fluoxetine remains unknown. In BED, CBT is effective in
reducing binge eating and leads to greater rates of abstinence,
persisting for up to 4 months after treatment; however, it does
not lead to weight loss. Medications may also play a role in
treatment although further research addressing how best to
achieve both abstinence from binge eating and weight loss in
overweight patients is required. We uncovered weak to no
evidence to address sociodemographic differences concerning
treatment or outcomes for any of these disorders.
Conclusions: The literature regarding disorder outcomes and
treatment efficacy for AN, BN, and BED is of highly variable
quality.
Implications for Policy, Delivery, or Practice: AN and BN
are associated with substantial morbidity and mortality and
exert a sizable impact on individuals and their families.
Problems associated with BED are gaining attention,
particularly as a behavior associated with obesity. There is
much that is not known about factors associated with worse
outcomes and effective treatment approaches. For all three,
exploring additional treatment approaches is warranted and
researchers should pay greater attention to factors influencing
outcomes, harms associated with treatment, and differential
efficacy by sex, age, race, ethnicity, and cultural group.
Primary Funding Source: AHRQ, NIH Office of Research on
Women's Health
●National and State Level Prevalence, Characteristics and
Health Care and Well Being of Children with Chronic
Emotional, Behavioral, or Developmental Problems
Requiring Treatment or Counseling
Christina Bethell, Ph.D., M.B.A., M.P.H., Debra Read, M.P.H.,
Stephen Blumberg, Ph.D.
Presented By: Christina Bethell, Ph.D., M.B.A., M.P.H.,
Associate Professor, Pediatrics, Oregon Health and Science
University, Mailcode CDRCP, 707 SW Gaines Street, 972393098; Tel: 503-494-1892; Fax: 503-494-2475; Email:
bethellc@ohsu.edu
Research Objective: To estimate the prevalence,
characteristics and health care and well being of children with
special health care needs (CSHCN) who have onging
emotional, behavioral, or developmental (EBD) problems
requiring treatment or counseling.
Study Design: Data from the National Survey of CSHCN (NSCSHCN) were used to estimate the prevalence and
characteristics of CSHCN age 0-17 with EBD problems
nationally and across states and to generate odds ratios (OR)
comparing CSHCN with and without ongoing EBD problems
on 15 key child and family health and health care indicators
produced by the NS-CSHCN.
Population Studied: A nationally representative sample of
children age 0-17 included in the NS-CSHCN (n = 372,174). A
child was conservatively defined as being in the CSHCN EBD
subgroup if the child met the CSHCN Screener criteria and the
parent reported that the child needed or received treatment or
counseling for an ongoing emotional, behavioral, or
developmental problem in the past 12 months.
Principal Findings: Among all children, 3.7% (range among
states: 2.8%–5.4%) met CSHCN criteria and had parentreported EBD problems. These children represented 28.7% of
all CSHCN nationally (range among states: 23.8%–35.3%). The
prevalence of chronic EBD problems requiring treatment or
counseling was greatest among children living in poverty
(5.5%), adolescents aged 12–17 years (5.0%), and boys (4.7%).
Compared with children with other special health-care needs,
children with EBD problems were significantly more likely to
have 1) health conditions that affect their daily activities (OR:
4.95):, 2) missed >11 days of school during the past year (OR:
1.54), 3) no health insurance or inadequate insurance
(OR:1.62), 4) unmet needs for health-care services (OR: 6.53),
5) difficulty obtaining referrals (OR:2.41), and 6) $1,000 or
more in annual out-of-pocket medical expenses (OR: 1.72).
Children with EBD problems were also more likely not to have
a personal doctor or nurse (OR: 1.51) and not to receive familycentered care (OR: 2.17). In addition, children with EBD
problems were more likely to have family members who 1)
experienced financial problems related to the child's health
(OR: 2.40), 2) reduced work hours or stopped working to care
for the child (OR: 2.26), and 3) spend >11 hours per week
providing or coordinating health care for the child (OR: 1.72).
Conclusions: Children with EBD problems constitute a
substantial subgroup of CSHCN and are at increased risk for
not receiving the services and supports they and their families
need.
Implications for Policy, Delivery, or Practice: Results
reinforce existing national recommendations which encourage
promoting the healthy emotional, behavioral, and cognitive
development of children through early recognition and
effective intervention for mental health problems. Expansions
in screening and early detection of EBD health problems, as
well as improvements in access, coordination, and quality of
health care services for children with EBD problems is
indicated.
Primary Funding Source: CDC, Health Resources and
Services Administration
●Factors Associated with Adoption of Buprenorphine by
Substance Abuse Treatment Organizations
Sarita Bhalotra, MD, Ph.D., Timothy Martin, Ph.D., Stanley S.
Wallack, Ph.D., Jon A. Chilingerian, Ph.D., Sharon Reif, Ph.D.,
Grant Ritter, Ph.D.
Presented By: Sarita Bhalotra, MD, Ph.D., Schneider INstitute
for Health Policy and Management, Heller School for Social
Policy and Management, 415 South Street, MS 035, Waltham,
MA 02454; Tel: (781)736-3960; Fax: (781) 736-3985; Email:
bhalotra@brandeis.edu
Research Objective: Despite legislation allowing office-based
physicians to offer Schedule III-V addiction medications, and
its enormous potential for enhancing the cost-effective
management and treatment of heroin dependence, uptake of
buprenorphine treatment for opiate-dependent persons has
been slow. The theoretical and empirical literature regarding
how organizations behave and change has provided important
insights into the adoption of new technology, but a complete
understanding of the factors influencing adoption is still
elusive. This study is aimed at a better understanding of what
characteristics of organizations influence the adoption of new
technology such as buprenorphine
Study Design: We conceptualized organizations as being
comprised of three internal systems: technical: governing
technology and task performance; political: relating to power
exercised by different stakeholders; cultural: driving the norms
and values of the organization. We hypothesized that
organizations would be more likely to adopt buprenorphine if
certain attributes of all three systems were present and
consistent with its mission, resources, and service capabilities.
We constructed a survey to capture these domains, and
conducted it via internet followed by telephone follow-up, in
organizations providing substance abuse treatment in four
geographically dispersed metropolitan market areas.
Population Studied: Of the 125 responses (51% response
rate), 26 organizations (21%) were identified as using
buprenorphine. In order to determine what organizational
attributes were associated with adoption of office-based
prescribing of buprenorphine, we performed bivariate and
multivariate analyses comparing buprenorphine adopters to
non-adopters.
Principal Findings: We collapsed organizational attributes
that distinguished adopters from non-adopters into six
categories labeled “atmosphere”, “communication”, “degree
of system receptiveness to new technology”, “patient
attributes”, “scope of service”, “healthcare system attributes”,
and “treatment orientation”. We estimated a Logit model to
predict the probability of adoption based on the most
significant variables within the six categories. Using
correlations, we grouped items into political, social, and
cultural categories, choosing variables that were most
representative of the class. We then used stepwise selection to
choose the final model. Additionally, factor analysis was
performed; four variables loaded onto political and cultural
domains, and three onto the technical domain.
Conclusions: The technical system had the largest impact on
buprenorphine adoption in this model (e.g. number of
services, number of FTEs, using prescription medications in
addictions treatment), but cultural (e.g. staff attitudes) and
political (e.g. close relationships between physicians and other
clinicians) characteristics were also significant predictors of
buprenorphine adoption.
Implications for Policy, Delivery, or Practice: Moving
research to practice is particularly important in substance
abuse treatment because of the costs of substance abuse and
funding to develop new medications. As pharmaceuticals play
an increasingly significant role in addictions treatment, it is
vital to understand the barriers to diffusion of
pharmacological therapies into clinical practice. Studies such
as the one described here can offer important public policy
guidance, and identify specifically targeted organizational
solutions to the challenge of translating research into practice.
Specifically, by identifying the key organizational factors that
promote adoption, these findings have implications for the
successful diffusion of buprenorphine into office-based
practices, and improving treatment for the growing number of
opiate-dependent persons.
Primary Funding Source: NIDA
●An Exploration of Diagnoses and Pharmaceutical
Treatment for Mental Illness among Elderly Nursing
Home Residents.
John Bowblis, M.A., Carrie Levin, Ph.D., Ayse Akincigil, Ph.D.,
Stephen Crystal, Ph.D.
Presented By: John Bowblis, M.A., Research Assistant,
IHHCPAR and Dept. of Economics, Rutgers University, 75
Hamilton St, New Brunswick, NJ 08901; Tel: (732) 932-8111;
Fax: (732) 932-6872; Email: jbowblis@ifh.rutgers.edu
Research Objective: To describe the clinical diagnoses
associated with mental illness (MI) documented on Minimum
Data Set (MDS) assessments as well as use of psychotropic
medications among nursing home (NH) residents.
Study Design: A retrospective, observational study of Ohio
NH residents using their annual MDS assessments.
Population Studied: 88,719 NH residents aged 65 and above
for whom an annual MDS assessment was completed
between January 1, 1999 and January 31, 2000.
Principal Findings: Residents were categorized according to
the type of medication received (antidepressant, antipsychotic,
antianxiety, and no psychotropic medication) as well as type of
mental illness diagnosis documented on their annual MDS
assessment (depression, manic depression, schizophrenia,
anxiety, and no MI). Mental illness was prevalent in this
population with 56.2% of residents having at least one MI
diagnosis. Most prevalent was depression (46%), followed by
anxiety (19.1%), schizophrenia (6%), and manic depression
(2.4%). More than half of all residents (56.7%) received one
type of psychotropic medication, with 40.7% of residents
receiving antidepressants, 22.2% antipsychotics, and 16.5%
antianxiety medications. Of those receiving one of the three
psychotropic medications, 18.7% did not have a
corresponding diagnosis of depression, anxiety,
schizophrenia, or manic depression. On the other hand,
10.1% had a MI diagnosis (depression, manic depression,
anxiety, and schizophrenia), but were not receiving any
psychotropic pharmacotherapy. Analysis revealed that
residents with a MI diagnosis who received psychotropics,
compared to those who did not have one of these four
diagnoses, were significantly more likely (p-value < .05) to
have physical comorbid conditions such as diabetes, heart
disease, arthritis, osteoporosis, stroke, and renal failure.
Those who received psychotropics without a MI diagnoses
were more likely to have cognitive impairment such as
Alzheimer’s disease (30.8% vs. 18.3%) and dementia (54.3%
vs. 47.9) compared to those who received psychotropics with
such diagnoses.
Conclusions: The use of antidepressant, antipsychotic, and
antianxiety medications in the NH setting is high; yet a
significant portion of this medication use was not associated
with a corresponding documented mental illness diagnosis on
a resident’s chart. Nearly 19% of all residents receiving a
psychotropic were doing so without a corresponding mental
illness diagnosis, though they were more likely to have
comorbid cognitive impairment such as Alzheimer’s disease
or dementia. Conversely, 18% of all residents had a diagnosis
of depression, manic depression, schizophrenia, or anxiety
disorder, but were not receiving psychotropic medication.
Implications for Policy, Delivery, or Practice: Providing
adequate and appropriate treatment for mental illness is an
integral part of improving the quality of mental health care in
NHs, yet our results indicate that many residents are receiving
inappropriate medications without being diagnosed with a
mental illness, while others are not receiving pharmacotherapy
when presumably they should be. The significant use of
psychotropic pharmacotherapy in residents without mental
health diagnoses suggests either off-label use of these
treatments for other conditions or behavior management, or
else their use for mental health problems that were
undocumented, perhaps because they entailed
symptomatology that was considered problematic, but not as
meeting formal criteria for a diagnosis.
Primary Funding Source: NIMH, AHRQ
●Innovations in Preventive Mental Health Care Services
for Adolescents
Sara Buckelew, M.D., M.P.H., Yu, Jennifer, Ph.D., English,
Abigail, J.D., Brindis, Claire, Dr.P.H.
Presented By: Sara Buckelew, M.D., M.P.H., Adolescent
Medicine Fellow, Pediatrics, University of California, San
Francisco, 3333 California St Suite 245 Box 0503, San
Francisco, CA 94118; Tel: 415-476-9618; Fax: 415-476-6106;
Email: buckelews@peds.ucsf.edu
Research Objective: The objective of this study was to
examine several key state and local programs aimed to
improve mental health prevention for adolescents.
Adolescence is a critical time for the prevention of mental
health disorders. Adolescents may engage in high-risk
behaviors that affect their physical and mental health,
including violence, risky sexual behaviors and drug and
alcohol use. Mental illness in adolescence is associated with
recurrence into adulthood and increased risk of suicide.
Despite the potential benefits of preventive mental health
services during adolescence and an increasing interest among
states to incorporate prevention into their mental health
programs, little is known about the types of preventive
services available, or how such programs were designed,
funded, implemented and sustained.
Study Design: We conducted qualitative telephone interviews
with 8 representatives of state or local programming. A
convenience sample and snowballing sampling techniques
were used.
Population Studied: Interviewees consisted of program
directors from state and local public health and mental health
departments representing rural states to metropolitan urban
areas and academic researchers specializing in child and
adolescent mental health services.
Principal Findings: States and local communities offer a
variety of unique preventive mental health services for
adolescents. Program settings include school based health
centers, juvenile justice facilities, welfare offices, and both
health care and mental health care systems sites. Services
varied widely and included: 1. Public-service announcements
targeting adolescent designed to decrease stigma and
improve awareness; 2. Short term counseling for adolescents
without a DSM IV diagnosis but who have been identified as
in need of counseling services; 3. Screening programs
intending to identify those in need of additional mental health
services; 4. Educational programming for primary care
providers aimed to increase identification of adolescents in
need of services and to improve providers abilities to provide
services. Funding mechanisms include state general funds,
foundation grants, and Medicaid and SCHIP dollars for
programs providing direct services. The methods and the
extent of evaluation conducted varied by the program and
funding mechanisms. Community awareness of services and
successes has been an important factor in sustainability for
several programs. Many interviewees identified a champion
who was critical to program development and sustainability of
services.
Conclusions: These findings demonstrate that many states
and local communities have used a variety of innovative
strategies to develop and maintain preventive mental health
services for adolescents, despite limited resources. Funding
mechanisms can be identified to provide these services.
Evaluation of these programs will be critical to both the
sustainability of existing programs and development and
funding of similar programs in other states and communities.
Implications for Policy, Delivery, or Practice: This research
may provide information to other states and communities
considering program development in adolescent preventive
mental health services. In addition, this research supports the
necessity of existing programs to continue to evaluate their
programs in order to maintain and sustain these services and
to continue to persuade funders and other stakeholders of
their importance.
Primary Funding Source: No Funding
●Communication about Behavioral Risks in the First
Obstetric Visit
Judy Chang, M.D., M.P.H., Diane Dado, M.S.W., Richard
Frankel, Ph.D., Robert Arnold, M.D.
Presented By: Judy Chang, M.D., M.P.H., Assistant Professor,
Obstetrics, Gynecology and Reproductive Sciences, University
of Pittsburgh, 300 Halket Street, Pittsburgh, PA 15213; Tel: 412641-6665; Fax: 412-641-1133; Email: jchang@mail.magee.edu
Research Objective: The first obstetric visit generally involves
a thorough discussion between the obstetrician and pregnant
patient regarding various behavioral risks including: smoking,
drug use, alcohol use and violence. Although such discussions
represent standard of care for the first prenatal visit, there is
little information about how obstetricians handle these topics.
To verify that screening and counseling are sensitive and
specific in terms of eliciting the full spectrum of patient
concerns and accurate information, we need to better
understand how physicians and patients are discussing these
issues. Our study objective was to examine patient-provider
communication on health risk behaviors during the first
prenatal visit.
Study Design: We audiotaped 9 first obstetric visits between
resident obstetricians and pregnant clinic patients. Behavioral
risks communication was analyzed in terms of sequence,
semantics, and syntax.
Population Studied: Our participant population consisted of
first, second, third and fourth year obstetrics and gynecology
resident physicians and pregnant patients presenting for their
first obstetric visit in a low-income hospital prenatal clinic.
Principal Findings: Six providers were involved in the 9
observations; all were female resident obstetriciangynecologists at various levels of training. Of the 9 patients,
four were black and 5 white; mean age was 24. Conversational
sequence was guided by the prenatal history form. Providers
rarely used introductory or transition statements to explain or
frame questions. Risk context consisted of questions that
emerged from the topics/questions discussed either before or
after risk screening (e.g., questions about depression/anxiety
occurred prior to questions about past violence; questions
about exposure to radiation or medications followed
questions about smoking or alcohol.) When asking about
violence or illicit drug use, providers tended to use multiple
methods of providing definitions or descriptions (i.e. “Any
abuse? Physical, sexual, emotional? Are you safe at home?”
and “Any drugs? Street drugs? Marijuana, cocaine, heroin?”)
Positive screening for tobacco, alcohol or drug use generated
generic discussions regarding harmful effects (i.e. “bad for
babies”) but rarely more detailed discussion of associated
harms. Responses to positive screening for past violence
ranged from no response to expressions of concern,
discussions of motional/psychological sequelae from past
abuse, and offers for referral, counseling, and social work
services.
Conclusions: Although obstetricians used multiple methods
of presenting and describing behavioral risks when screening,
they rarely provided explanations regarding the context and
reasons for addressing these sensitive and personal issues.
Responses to positive disclosure of tobacco, alcohol or drug
use during pregnancy generated general but not detailed or
specific discussion of possible associated harms.
Implications for Policy, Delivery, or Practice: With improved
knowledge of what techniques and methods of
communicating about health behaviors and risks can lead to
increased patient-provider trust, increased patient disclosure
and increased motivation for change, we can then develop
specific training interventions to assist providers in improving
health outcomes for women.
Primary Funding Source: Scaife Family Foundation;
APGO/Abbott Medication Education Program Award
●Assessing High Quality Depression Care in Diabetic
Patients by Primary Care Physicians
Johann Chanin, RN, MSN, Amanda Zides, M.H.S., Ann Chou,
Ph.D., M.P.H., Sarah Scholle, Dr.P.H., M.P.H.
Presented By: Johann Chanin, RN, MSN , National
Committee for Quality Assurance (NCQA), 2000 L Street,
Suite 500, Washington, DC 20036; Tel: 202-955-3588; Fax: 202955-3599; Email: Chanin@ncqa.org
Research Objective: To identify and assess depression care
performance measures in diabetic patients by primary care
providers that could be used in pay-for-performance
programs.
Study Design: This study employed a mixed-methods design.
Diabetes management data from 35 consecutive eligible
patient records submitted by ten physicians were assessed for
depression care management during a 12-month evaluation
period. Descriptive statistics were compiled on patients
whose records documented: 1) Depression screening; 2)
Screening using a standardized tool; 3) Treatment, including
antidepressant medication, behavioral therapy and follow-up
appointments. Results in the aggregate were shared with each
physician during a qualitative interview to discuss their
strategies in depression management, facilitators and barriers
in providing depression care to diabetes patients, and their
views on depression care in pay-for-performance programs.
Population Studied: Ten physicians who had achieved
recognition for diabetes care through NCQA’s Diabetes
Physician Recognition Program (DPRP).
Principal Findings: Documentation of depression screening
was low. Of the ten physicians in the study, five physicians
screened a total of 11 patients for depression (11/350),
resulting in an average of 0.3 patients per physician and a
range of 0 to 4 patients per physician. Only one physician
reported using a standardized tool. Eight of ten physicians
prescribed an anti-depressant for a total of 32 patients during
the 12 month data collection period, an average of 3.2 patients
per physician and a range of 0 to 8 patients. The physicians at
the upper end of the range prescribed an anti-depressant to
23%of their 35 patients (8 of 35). Seven patients from four
physicians received counseling or other treatment from a
behavioral health specialist, averaging 0.2 patients with a
range of 0 to 4 per physician. A synthesis of the qualitative
interviews revealed that most physicians describe a process
for screening and treating patients with depression. However,
the process is often not systematic and a standardized
depression assessment tool is not used. Also, physicians
reported that they screened for and treated depression in their
diabetes patients far more than is recorded in patient records.
Most physicians supported pay-for-performance programs for
depression care but identified many structural and patientrelated barriers to providing such care.
Conclusions: Depression is common among diabetes
patients and is strongly linked to success in managing
diabetes. Physicians who achieve high performance in the
management of diabetes care in our study rarely screened
their diabetes patients for depression. Nearly all participating
physicians opted not to use a standardized tool for assessing
patients. The study indicates ample room for physicians to
improve the provision of depression care for patients with
diabetes.
Implications for Policy, Delivery, or Practice: Efforts to
facilitate and incentivize better management of depression by
primary care physicians are warranted. By and large,
physicians indicated an interest in programs that will facilitate
improvement in assessing and managing depression
screening and treatment for patients with chronic, high-risk
medical conditions, including the use of a standardized
assessment tool.
Primary Funding Source: RWJF
●The Heterogeneity of Aggressive Acts Among Inpatients
with Schizophrenia: Concurrence and Correlation from
Past History to Prospective Occurrence
Cynthia Shing-Chia Chen, Ph.D.
Presented By: Cynthia Shing-Chia Chen, Ph.D., Senior
Lecturer, School of Nursing, College of Medicine, National
Taiwan University, No. 1, Jen-Ai Road, Section 1, Taipei, 10051;
Tel: 8862-23123456 x8433; Fax: 8862-23279621; Email:
scchen@ha.mc.ntu.edu.tw
Research Objective: The aim of this study was to understand
the heterogeneity of aggressive acts from past history and
prospective occurrence of overt aggressive acts among
inpatients with schizophrenia.
Study Design: Both of retrospective interviewing and
prospective observation method were used to collect counts
of past-month and initial-week aggressive acts toward property
(AggP), toward person (AggO), and toward self (AggS) by the
Chinese version of Violence Scale in a psychiatric unit of a
university-based teaching hospital. Chi-square test and
Pearson’s correlation statistic with Software of SPSS 12.0 were
applied to analyze the counts of aggressive acts, and the levels
of severity of aggressiveness.
Population Studied: All consecutively admitted adult patients
(>= 17 years old) confirmed with clinical diagnosis of
schizophrenia (SCZ) based on DSMIV (N=107) over a oneyear period were recruited.
Principal Findings: Findings revealed that 58.9% of subjects
had overt aggressive acts and the average number was 10.5 at
the initial week of their admission. There was 85.0% of total
subjects had a history of past month aggressive acts. A high
concurrent rate of AggO with AggP (r = .52) existed, especially
with physical AggP (r = .51), whereas only physical AggO was
concurrent with AggS (r = .24) in the initial week after
hospitalization. There was a high significant correlation of the
severity of aggressive acts between corresponding and
outward categories of past-month and initial-week aggressive
acts (toward property, r= .46; toward persons, r = .50; toward
self, r = .41; and past-month AggP with initial-week AggO, r =
.34, and past-month AggO with initial-week AggP, r = .43),
whereas the correlation between aggressive acts toward self
and the other two categories were all low.
Conclusions: Overt aggressive acts among inpatients with
schizophrenia could be occurred in outward or inward group
but there is a risk of similar impulsivity to occur repeatedly.
Implications for Policy, Delivery, or Practice: The aggressive
patients usually could be identifiable from past-month
aggressive acts with the same pattern ordering of type and
subtypes. Results could be as a reference for psychiatric
service and further study.
Primary Funding Source: NIMH
●A Measure of Severity of Illness for Mental Illness and
Substance Use Disorders for Health Services Research
with Administrative Data: Validation against Decisions to
Admit Inpatients and Individuals’ Decisions to Use
Emergency Care Repeatedly
Rosanna Coffey, Ph.D., Robert Houchens, Ph.D., Bong-Chul
Chu, Ph.D., MHA, Pamela Owens, Ph.D., Rita VandivortWarren, MSW, Jeffrey A. Buck, Ph.D.
Presented By: Rosanna Coffey, Ph.D., Vice President,
Research Division, Thomson Medstat, 4301 Connecticut Ave,
NW, Suite 330, Washington, DC 20008; Tel: 202-719-7822;
Fax: 202-719-7801; Email: rosanna.coffey@thomson.com
Research Objective: The research objective for this paper was
to devise, apply, and test a measure of severity for both
mental illness (MI) and substance use disorders (SUD) that
can be used with administrative health care data to control for
severity in, and improve, health services research on MI and
SUD services. This measure was applied in the context of
emergency department (ED) care and its repeated use.
Study Design: The study used administrative data on hospital
emergency department visits and hospital stays in which
individuals were identified and tracked over time and place.
Severity was formulated from the recently published results of
the National Comorbidity Survey–Replication (NCS-R), which
used survey data to assess disability and impairment in
relation to DSM-IV mental and substance use disorder
diagnoses. ICD-9-CM codes, which align with the DSM-IV and
are available in administrative data, were grouped to represent
mild, moderate, and severe conditions based on the
probability of disability or impairment among the populations
with given diagnoses. The validity of this configuration of ICD
codes to represent severity of MI and SUD was tested among
users of ED services to distinguish those admitted versus
those treated and released and to distinguish those using EDs
rarely versus frequently. Hierarchical linear models were used
to eliminate the confounding effects of clustering of patients
within hospitals and communities.
Population Studied: Adults 18 and older with MI and SUD
who used ED services, using data from the State Emergency
Department Databases and State Inpatient Databases from 2
states that participate in the Agency for Healthcare Research
and Quality (AHRQ) Healthcare Cost and Utilization Project
(HCUP). One State is in the South and one in the Midwest.
Principal Findings: Among ED users, the MI and SUD
severity measures were strong predictors of both the rate of
ED use and the likelihood of inpatient admissions. The newly
formulated MI and SUD severity groups were important
predictors of repeat ED utilization and hospital admission
rates among MI and SUD patients who visit the ED. The
estimated ED use rates and inpatient admission rates
increased monotonically with severity, after controlling for
patient demographics, hospital characteristics, and the
availability of selected health services in the patient’s county of
residence.
Conclusions: In studying health care utilization for MI and
SUD using administrative data, it is important to account for
the effects of MI and SUD severity. The NCS-R findings can
be used to develop a severity measure from ICD/DSM-IV
diagnoses that have face validity in such utilization research.
Implications for Policy, Delivery, or Practice: This
classification of severity of illness based on the NCS-R and
ICD/DSM-IV diagnoses is a novel contribution to behavioral
health care research. It will enable researchers to test
hypotheses about relationships between policy interventions
and health care utilization while controlling for a critical
element in the use of health care services—severity of illness.
Primary Funding Source: AHRQ, SAMHSA
●Access to Mental Health Services for Medicaid
Recipients in Colorado: Effects of Management Strategy,
Ownership, and Rates
Janet Coffman, MPP, Ph.D., Neal Wallace, Ph.D., Soo Kang
Pak, Ph.D., Joan Bloom, DrPH
Presented By: Janet Coffman, MPP, Ph.D., Senior Research
Analyst, Institute for Health Policy Studies, University of
California, San Francisco, 3333 California Street, Suite 265, San
Francisco, CA 94118; Tel: 415-476-2435; Fax: 415-476-9795;
Email: Janet.Coffman@ucsf.edu
Research Objective: Experts have expressed concern that
Medicaid beneficiaries with severe and persistent mental
illness (SPMI) may have difficulty obtaining appropriate care
in capitated mental health systems. Previous studies have not
addressed long-term effects of variation in ownership type,
strategy for managing capitation payments, and capitation
rates on access to care in capitated mental health systems.
This study assessed the impact of these factors on the
numbers of consumers served and severity of mental illness.
Study Design: The study examined data from the Colorado
Client Assessment Record, a mental health assessment
instrument administered upon admission or discharge from
treatment. Records for individual Medicaid recipients were
aggregated to generate quarterly observations for seven
mental health assessment and services agencies (MHASAs)
created by Colorado to deliver mental health services to
Medicaid recipients. We analyzed trends in the numbers of
consumers admitted or discharged from treatment, average
severity of illness, and percentage of consumers with SPMI.
The study compared two groups of MHASAs: 1) four
MHASAs operated directly by not-for-profit community mental
health centers (CMHCs), and 2) three MHASAs that were forprofit joint ventures between CMHCs and a for-profit
managed behavioral health organization. A difference in
difference model with fixed effects was estimated to examine
trends over a six and three-quarter year period following the
implementation of capitation.
Population Studied: Adults enrolled in Colorado’s Medicaid
program who utilized mental health services from October
1996 through June 2002.
Principal Findings: The number of consumers admitted by
the not-for-profit CMHCs decreased over time, and average
severity at admission and the proportion of consumers with
SPMI increased. In contrast, admissions to the for-profit joint
ventures increased, average severity did not change, and the
percentage of consumers with SPMI decreased only slightly.
Following a decrease in capitation rates during the sixth year
of capitation, admissions to the not-for-profit CMHCs
decreased more rapidly and growth in admissions to the forprofit joint ventures slowed.
Conclusions: Our findings that admissions increased and
that average severity of illness at discharge did not increase in
the for-profit joint ventures are not consistent with the
conventional wisdom that access to care is worse in for-profit
organizations than in not-for-profit organizations. Instead,
our results are best explained by differences in the strategies
the two types of capitated systems used to manage capitation
payments. The decrease in the number of consumers served
and increases in average severity and percent of clients with
SPMI found among the not-for-profit CMHCs are consistent
with a strategy that emphasizes intensive management of
persons with SPMI. The increase in admissions and lack of
change in average severity among the for-profit joint ventures
reflect a strategy of providing services to all consumers as
efficiently as possible.
Implications for Policy, Delivery, or Practice: Our findings
are highly relevant to state policymakers. We find no evidence
that for-profit organizations provide poorer access than notfor-profit organizations. The decreases in admissions to both
types of capitated systems following the reduction in
capitation rates suggest that reducing rates may jeopardize
access to mental health services.
Primary Funding Source: National Institute on Mental
Health
●Patterns of Depression Diagnosis and Antidepressant
Use Among Elderly and Non-Elderly Medicaid
Beneficiaries
Stephen Crystal, Ph.D., Scott Bilder, Asye Akincigil, James
Walkup, Carrie Levin
Presented By: Stephen Crystal, Ph.D., Director, Center for
HSR on Pharmacotherapy, Chronic Disease Management, and
Outcomes, Rutgers, 30 College Ave, NJ 08540; Tel: 732-9328579; Email: scrystal@rci.rutgers.edu
Research Objective: Depression among the elderly has
traditionally been considered underdiagnosed and
undertreated. However, with the advent of newer classes of
antidepressant medications, antidepressant use rates have
considerably increased in recent years both among elderly and
non-elderly populations. Much remains to be understood,
about the way in which these potent medications are being
prescribed and managed, and about quality of depression
care. This is particularly true when care is managed by
primary care physicians without specialty mental health
involvement, which is increasingly the case. We examine
these issues in the Medicaid population, where they are
particularly significant, clinically and economically.
Study Design: We used 1999-2000 Medicaid Analytic Extracts
data for five states to examine patterns of depression
diagnosis and antidepressant use among elderly and nonelderly beneficiaries enrolled in fee-for-service care for a full
year. These fee-for-service beneficiaries were predominantly
(58%) dually eligible for Medicaid and Medicare, 64% were
female, and 44% were over age 65.
Population Studied: Medicaid beneficiaries over age 18
enrolled
in fee-for-service care for a full year.
Principal Findings: Initial analyses indicate that in 2000, the
proportion of beneficiaries receiving an antidepressant
medication during the year was 24% at ages 18-64, 19% at
ages 65-74, and 18% at ages 75+. Most beneficiaries with
diagnostic indications of depression received antidepressants,
but the converse was not true. For all age groups, the
majority of antidepressant use took place without either a
diagnosis of major depressive disorder (ICD-9 codes 292.x or
293.x) or other diagnostic indications of depression (ICD-9
codes 298.0, 300.4, 309.0, 309.1, or 311.x). Even under the
most-inclusive definition that included the latter codes, the
proportion of antidepressant users with a depression
diagnosis was only 37% for those ages 18-64. Elderly
antidepressant users were even less likely to have a
depression diagnosis (19% at ages 65-74, and 14% at ages
75+). Only 21% of antidepressant users ages 18-64 had an
MDD diagnosis, compared with 11% at ages 65+ and 7% at
ages 75+. There were substantial racial-ethnic differences in
diagnostic and use patterns, with African American and Latino
beneficiaries less likely both to receive a depression diagnosis
and to receive antidepressants.
Conclusions: Antidepressant use is highly prevalent in the
Medicaid fee-for-service population, both for non-elderly and
elderly beneficiaries. Most of this use is not associated with a
diagnosis of depression, and this is even more strongly the
case in the elderly population.
Implications for Policy, Delivery, or Practice: An essential
step in improving depression care for Medicaid beneficiaries
is to better understand how physicians identify and address
depression-related problems and utilize antidepressants.
Widely used quality measures for depression treatment, such
as the HEDIS measures, focus on treatments received by
persons with diagnoses of depression in their claims files.
However, high rates of antidepressant use without
accompanying depression diagnosis raise important
questions about clinical intent. Possible scenarios include
very high rates of off-label use aimed at non-mental health
conditions; treatment aimed at other mental health
conditions; or widespread use with the intent of addressing
depressive symptoms but without claims-recorded diagnoses
of depression, or “stealth treatment” of depression. Further
research on these issues is needed.
Primary Funding Source: NIMH1, AHRQ
●Consequences of Military Service for Substance Use
Later in Life: An Instrumental Variables Approach
Daniel Eisenberg, Ph.D., Brian Rowe
Presented By: Daniel Eisenberg, Ph.D., Assistant Professor,
Health Management and Policy, University of Michigan,
M3517 SPH II, Ann Arbor, MI 48109-2029; Tel: (734) 615-7764;
Fax: (734) 764-4338; Email: daneis@umich.edu
Research Objective: With recent military engagements in Iraq
and elsewhere, it is important for the Veterans Health
Administration and other providers to understand the
potential effects of military service on substance use. Studies
have shown that men who served in Vietnam were more likely
to smoke, drink alcohol, and use other substances later in life
than their peers who did not serve. It is not clear, however,
whether these differences were due to service-related effects or
to differences in personal characteristics that cannot be
controlled for in analyses (e.g. different preferences regarding
health risks, or higher discount rates). We addressed this
issue using an instrumental variable (IV) approach.
Study Design: IV estimates were constructed in two steps, as
in the following example. First, smoking rates following the
war were compared between two groups: men with low draft
numbers (more likely to be drafted) and men with high draft
numbers (less likely to be drafted). Second, this difference in
smoking rates was divided by the difference across the groups
in likelihood of serving in Vietnam. This type of analysis has
been previously conducted looking at outcomes such as
mortality due to accidents (Hearst et al 1986) and wages
(Angrist 1990). Because draft numbers were based on
random selection of birth dates, groups defined by draft
numbers did not differ significantly in terms of any personal
characteristics. The simple IV calculation described above
was also extended to a two-stage least squares framework, in
which we controlled for education, race/ethnicity, region, and
income. Individual-level data on smoking habits and other
characteristics were taken from all of the annual National
Health Interview Survey (NHIS) data sets between 1980 and
2002. Using the CDC’s Data Research Center we linked draft
number intervals (e.g. 1-20, 21-40, etc) to individual
observations based on birth dates.
Population Studied: Our sample from NHIS (1980-2002)
included approximately 200,000 men who were potentially
eligible for the Vietnam draft (born between 1944 and 1953).
Principal Findings: Data analysis is ongoing. We have
prepared the programming code for the analysis and will apply
it to the restricted data at the CDC during a scheduled visit in
March. We hypothesize that the IV analysis will suggest a
smaller effect of military service on substance use than
previous ordinary least squares estimates, due to greater
tastes for risk among people who serve.
Conclusions: Results are not yet available, as noted above.
Implications for Policy, Delivery, or Practice: Our findings
will improve the understanding of the health-related
consequences of military service. This understanding should
be helpful for optimizing care for current and future veterans:
we will have more accurate forecasts for the needs for services
and a better understanding about whether substance use
problems are more related to the consequences of service or
to personality traits. We will also have a better understanding
of the potential health-related consequences of engaging in
military actions.
Primary Funding Source: American Legacy Foundation
●Service Use by University Students with Depression:
Barriers and Unmet Needs
Daniel Eisenberg, Ph.D., Ezra Golberstein, Sarah Gollust,
Jennifer Hefner, M.P.H.
Presented By: Daniel Eisenberg, Ph.D., Assistant Professor,
Health Management and Policy, University of Michigan,
M3517 SPH II, Ann Arbor, MI 48109-2029; Tel: (734) 615-7764;
Fax: (734) 764-4338; Email: daneis@umich.edu
Research Objective: Mental health is perhaps the greatest
health concern for young adults. In recent national surveys,
most directors of college counseling centers have reported
growing mental health problems among their students. It is
important to understand how well these growing needs for
mental health services are being met, and how access to
services can be improved. Our study is the only one in recent
years, to our knowledge, to examine mental health needs and
use of services using validated instruments in a large and
representative university student sample. Our primary aims
are to quantify unmet needs and to assess how they relate to
insurance status, financial situation, and knowledge, attitudes,
and beliefs about services.
Study Design: Using survey data we estimated unmet need
for mental health services by identifying people who had
probable depression (using the Patient Health Questionnaire
(PHQ-9)) but who did not use any prescribed psychotropic
medication or therapy or counseling services in the past year.
We then used logistic regressions to examine the relationship
between unmet needs and factors including demographic
characteristics, financial status, insurance status, and
knowledge, attitudes, and beliefs about services. To assess
the importance of these factors in different stages of the careseeking process, we separately examined predictors of
perceived need for services, and receipt of services given
perceived needs. All regressions were weighted to adjust for
differential non-response by demographic groups. We also
assessed possible biases in the composition of our sample by
conducting a shorter follow-up survey with more intensive
recruiting strategies for a sub-sample of non-respondents.
Population Studied: Our sample includes 2,879
undergraduate and graduate students from a large
Midwestern university who completed a web-based survey in
November 2005. The survey was sent to a random sample of
students and achieved a 60 percent response rate.
Principal Findings: 405 students (14 percent) had a probable
depressive disorder. Sixty six percent of these students
reported they thought they had a need for mental health
services in the past year, but rates of service use were much
lower: 25 percent used a prescribed psychotropic medication,
26 percent received counseling/therapy, and 37 percent used
at least one of these two types of services. Preliminary results
indicate that although students commonly perceived a public
stigma on using mental health services, this attitude was not
associated with the likelihood of perceiving a need for services
or receiving services. The most notable factors associated
with a lower likelihood of receiving services included financial
difficulties, skepticism about the effectiveness of treatments,
and lack of awareness of service options.
Conclusions: The majority of students with probable
depression received no mental health services in the past year,
even though most acknowledged a need for services. A variety
of barriers appear to have impeded the help-seeking process,
including financial constraints and beliefs and knowledge
about the effectiveness and availability of service options.
Implications for Policy, Delivery, or Practice: Our results
suggest that multi-faceted interventions on campuses to
improve access to services are likely to be beneficial. Such
interventions should aim to promote awareness of service
options, minimize financial barriers, and educate students
about the effectiveness of services.
Primary Funding Source: Blue Cross Blue Shield Foundation
of Michigan
●Diffusion of Prescription Drugs for Alzheimer’s Disease
(AD) Among Older Adults
Chandrakala Ganesh, BPharm, M.B.A., Dennis G Shea, Ph.D.
Presented By: Chandrakala Ganesh, BPharm, M.B.A., Ph.D.
Candidate, Health Policy and Administration, Penn State
University, 262 East Squire Drive, Apt 8, Rochester, NY 14623;
Tel: (585)414-1709; Email: cxg913@psu.edu
Research Objective: This paper has three objectives: (1) to
examine the trends in diffusion of Alzheimer’s disease (AD)
drugs among community residing Medicare beneficiaries from
1993 to 2002, (2) to determine the racial, ethnic and
socioeconomic disparities in diffusion of AD drugs, (3) to
identify determinants of current and projected future costs of
AD drugs.
Study Design: The study design involves analysis on 10 years
of MCBS data. Analysis procedures would be conducted on
three samples: beneficiaries with only a claims diagnosis of
AD, beneficiaries with a claims diagnosis or a survey report of
AD, and beneficiaries with a claims diagnosis of AD, survey
report of AD, or other dementia diagnosis. This categorization
would help in determining how the results would change
based on varying sample definitions. Analyses procedures will
include conducting basic descriptive analysis on the numbers
and types of drugs that are used by elderly with AD. Hazard
models will be used to estimate the trends and disparities in
diffusion of AD drugs. Finally, costs would be estimated by a
generalized linear model using gamma regression functions.
Population Studied: The sample includes communitydwelling Medicare beneficiaries who were enrolled in fee-forservice Medicare through the calendar year. Beneficiaries who
had a survey report or a claims diagnosis of AD, and who
completed the MCBS survey questionnaire are included in the
sample. Only those beneficiaries who had a claims diagnosis
and a completed the survey component are included to
increase the validity of the measure and to avoid possible
misclassification that might result from using claims data
alone. Beneficiaries who reside in nursing homes are
excluded. In addition data on health care systems from the
2003 Area Resource File will be used.
Principal Findings: Each year about 3.5 percent of the
community dwelling Medicare beneficiaries suffered from AD.
Cholinesterase inhibitor use increased from 1.4 percent in
1999 to 31 percent in 2001. In general, beneficiaries who were
white, lived in urban areas, had higher education, with drug
coverage had greater utilization rates of AD drugs than those
who were black, in rural areas, with lower education, without
drug coverage. In 2001, the mean annual total drug and outof-pocket expenditures of beneficiaries using AD drugs were
$2317 and $850 respectively, versus $1749 and $663 for
beneficiaries not using AD drugs.
Conclusions: Preliminary studies suggest that new drug
technology for AD has a significant impact on health care
utilization and health care costs
Implications for Policy, Delivery, or Practice: The
introduction of several new drugs for the treatment of AD
makes it an ideal candidate for the study of diffusion. This
paper will unfold the impact of new drug technology on health
care utilization and health care costs in AD. In addition, it will
help in understanding how socioeconomic status and
minority group membership influence drug treatment sought
by beneficiaries with Alzheimer’s disease.
Primary Funding Source: No Funding, A poster on
"Sociodemographic Correlates of Medicare Beneficiaries with
Alzheimer's Disease" was presented at the 2004 Academy
Health conference
●Does Initiation and Engagement in Substance Abuse
Treatment Decrease the Likelihood of Arrest and
Incarceration?
Deborah Garnick, Sc.D., Constance Horgan, Sc.D., Margaret
Lee, Ph.D., Lee Panas, M.A., Grant Ritter, Ph.D., Steve Davis,
Ph.D.
Presented By: Deborah Garnick, Sc.D., Professor; Associate
Dean, Academic Personnel, Schneider Center for Behavioral
Health, Heller School for Social Policy and Management,
Brandeis University, 415 South Street - Mailstop 035, Waltham,
MA 02454-9110; Tel: (781) 736-3840; Fax: (781) -736-3985;
Email: garnick@brandeis.edu
Research Objective: Evaluate if meeting performance
measures that focus on the beginning of episodes of care for
substance abuse clients decreases the likelihood of arrest and
incarceration.
Study Design: We use substance abuse performance
measures originally developed by the Washington Circle (WC),
adopted by the National Committee on Quality Assurance
(NCQA) for commercial, Medicaid and Medicare managed
care plans, and under further development by ten public state
substance abuse agencies. These include initiation (percent
of clients with a new episode beginning with an outpatient
service who have an additional service in 14 days or who have
an initial residential stay) and engagement (two additional
services within 30 days after initiation). Survival analyses were
conducted to predict the influence of treatment initiation and
engagement, along with client demographic information,
previous criminal justice involvement and employment, type
of drugs used, and program variables, on the time to arrest or
incarceration.
Population Studied: The study uses encounter data from the
Oklahoma Department of Mental Health and Substance
Abuse Services linked to state criminal justice data for adult
clients who began a new episode of treatment with an
outpatient service (N = 5,163) in 2001.
Principal Findings: Clients first treated with outpatient
services and who initiated and engaged in treatment were less
likely to be arrested or incarcerated (hazard ratio = .73).
Initiation of treatment by itself, without engagement, was not
enough to significantly decrease the likelihood of
arrest/incarceration.
Conclusions: This study offers initial evidence that adherence
to substance abuse performance measures is associated with
a lower likelihood of serious negative outcomes such as
arrests/incarcerations for outpatient clients.
Implications for Policy, Delivery, or Practice: This study
shows the influence on an outcome that is critical both to
clients and society, criminal justice involvement, and
performance measures based on the concept of “process of
care” that are actionable in the short term through quality
improvement initiatives at substance abuse treatment
facilities.
Primary Funding Source: NIAAA, National Institute on Drug
Abuse
●How Can States Encourage More Effective Diagnosis and
Treatment of Child Mental Health Issues in Primary Care
Settings?
Sherry Glied, Ph.D., Michael Sparer, Ph.D.
Presented By: Sherry Glied, Ph.D., Professor and Chair,
Health Policy and Management, Mailman SPH, Columbia
University, 600 West 168th St., 6th Floor, New York, NY
10032; Tel: 212-305-3924; Fax: 212-305-3405; Email:
sag1@columbia.edu
Research Objective: The national shortage of child
psychiatrists prompts pediatricians to treat child mental
health problems. Mental health professionals and
pediatricians generally agree, however, that most pediatricians
lack the training and expertise to effectively diagnose and treat
mental health issues. The goal of this study is to identify and
evaluate innovative state Medicaid efforts to encourage
greater integration between pediatricians and mental health
professionals, and to consider whether and how such
innovations might be replicable
Study Design: Qualitative analysis of case studies in three
states: two leaders (Massachusetts and North Carolina) and
one laggard (New York). We also examined Medicaid claims
data from each of these states.
Population Studied: Medicaid beneficiaries aged 5-18.
Principal Findings: The leader states are implementing a
range of initiatives, which include telephone consultation, colocation, and case management.
Conclusions: Four variables seem to distinguish the leaders
from the laggard: 1) Massachusetts and North Carolina both
rely on primary care case management (while New York relies
almost exclusively on capitated managed care); 2) most
pediatricians in Massachusetts and North Carolina participate
in Medicaid (while relatively few do so in New York); 3) the
Massachusetts and North Carolina pediatric associations have
taken leadership roles in this arena (not the case in New York)
and 4) state policymakers have funded the innovative pilot
programs (again, not so in New York).
Implications for Policy, Delivery, or Practice: States can
improve mental health provision for children in Medicaid
primary care. The interest and ability to take such steps
depends critically on the organization of the Medicaid
program in the state.
Primary Funding Source: MacArthur Foundation
●A Quality Improvement Process Monitoring Prescribing
Practices for Low dose Quetiapine Fumarate and
Gabapentin in the Inpatient Psychiatric Setting
Kalyani Gopalan, MS, M.H.A., Roger Haskett, M.D., Ken
Nash, M.D., Frank A. Ghinassi, Ph.D., Karen Fielding,
Pharm.D., David White, M.H.A.
Presented By: Kalyani Gopalan, MS, M.H.A., Analyst, Clinical
Outcomes, UPMC-Western Psychiatric Institute and Clinic,
3811 Ohara street, room 558, Pittsburgh, PA 15213; Tel: (412)
246-5198; Fax: (412) 586-9057; Email: gopalank@upmc.edu
Research Objective: Research shows the prevalence of
polypharmacy and the increasing cost of psychotropic
medications are not consistently accompanied by
corresponding improvements in quality of psychiatric care. For
example, the use of low doses of quetiapine as a hypnotic or
anxiolytic exceeded the evidence supporting its efficacy. This
study monitored clinical indications for initiating treatment
with these medications and aimed to reduce the utilization
and total cost of this drug during inpatient stay.
Study Design: Secondary data from pharmaceutical
information systems were reviewed and analyzed during the
study period to flag any new prescriptions of quetiapine at a
daily dose of less than or equal to 200mg and or any new
prescriptions of gabapentin. Summary reports containing
medication and dosage by prescribing physician were emailed
to the Medical Director and Service Chief for the physicians in
their respective service who then contacted the physicians and
determined the indication for the medication.
Population Studied: All patients who were admitted to the
inpatient unit of WPIC from July 2005 onwards.
Principal Findings: A 75% and 53% decrease in flagged
prescriptions of Quetiapine and Gabapentin respectively from
July 2005 to December 2005. A 39% reduction in number of
prescriptions with low dose quetiapine from Q4 of 2005 to Q1
of 2006. Analyses with respect to overall cost impact are
continuing.
Conclusions: (1) Establishing a system to access and analyze
pharmacy data, while not without challenges, is a valuable
component to clinically based quality improvement initiatives
(2) The availability of pharmacy data provides for assessing
prescribing patterns of psychoactive medications (3) Instances
of low dose quetiapine and prescription of Gabapentin were
found to be prevalent but not always supported by best
practice indication as onitored by the intervention. (4) The
before/after utilization profiles, of the specific medications,
suggests that the intervention was effective in reducing
unhelpful variation. Judgments about cost offsets, with respect
to substituted alternatives and in relation to justifying the cost
of monitoring, are still under investigation.
Implications for Policy, Delivery, or Practice: Various
findings in the literature suggest that polypharmacy with
psychotropic drugs occurs frequently in the treatment of
psychiatric diseases. Polypharmacy is usually reserved for
documented cases of failed mono-therapy with multiple trials
or instances of cross taper still in progress. Nevertheless,
there are still substantial deficits in established knowledge
about combination and augmentation therapies. When a
particular topic is identified by medical staff leadership having
mechanisms in place to conduct relevant analyses and
provide feedback can help in changing behaviors and
ultimately contributes to the quality of care.
Primary Funding Source: UPMC – Western Psychiatric
Institute and Clinic
●Otitis Media Affects Early Development For High-Risk
Children
Roy Grant, MA, Lourdes Lynch, Ph.D., Sharon Joseph, M.D.,
Irwin Redlener, M.D.
Presented By: Roy Grant, MA, Director of Research, Policy,
The Children's Health Fund, 215 West 125th Street, New York,
NY 10027; Tel: 212-535-9400; Fax: 212-535-7699; Email:
rgrant@chfund.org
Research Objective: There is an extensive literature exploring
the potential association between otitis media (OM) and
developmental delay. Results have been mixed. In one large
study (Paradise et al. 2000) it was not possible to differentiate
OM from other risk factors associated with developmental
delay. Meta-analyses of published studies have concluded that
evidence of an association between OM and developmental
delay was “uncertain” (Roberts et al. 2004); “undetermined”
(Smits-Bandstra 2004); or “markedly low” (Casby 2001). The
present study explores the impact of OM on diagnosed
developmental delay in a population known to be at high risk,
homeless young children (Parker et al. 1991; Grant 1991).
Study Design: Electronic health records were reviewed for all
patients <60 months old (N=333) identified with
developmental and/or behavioral problems by their
pediatrician and diagnosed by a clinical psychologist between
1998 and 2004 at the New York Children’s Health Project
(NYCHP), a service of The Children’s Health Fund. A
comparison sample was drawn from a random chart review of
homeless NYCHP patients <60 months old (N= 317) seen
during calendar year 2004. In addition to OM history, we
recorded the following potential confounding variables: low
birth weight, high lead levels, anemia, and domestic violence
(DV) exposure.
Population Studied: The population was comprised of
homeless children domiciled in the city's family shelter
system. Demographics: 58% Black,40% Hispanic, 2% other.
Mean ages: 35 months (referred patients); 24 months
(comparison).
Principal Findings: Overall OM prevalence in the referred
population was 42%; for patients 3-23 months old it was 50%;
for 24-59 months old, 34%. In the comparison sample, OM
prevalence was lower to a statistically significantly degree:
overall, 31% (p<.01); 3-23 months, 35% (p<.01); 24-59 months,
21% (p<.05). Because of the transient nature of homeless
populations, we do not have consistent full year utilization
data. Those patients with OM seen over time had recurrences
at 4-6 week intervals. Prevalence of low birth weight and
plumbism were <5% in both samples. Anemia was not
significantly associated with developmental delay. DV
prevalence did not differ significantly (39% in the referred
sample vs. 35%).
Conclusions: In this large sample of high-risk young children,
otitis media was significantly associated with developmental
delay. Persistence of OM into early childhood may be a
contributing factor. These findings suggest that OM is best
understood as a risk factor rather than a cause for
developmental delay. Our findings are consistent with the
understanding that risk factors are most likely to have a
negative impact when clustered with other risk factors
(Gutman & Sameroff 2003; Sameroff et al. 1987). Our findings
are consistent with the model that the impact of OM may be
mediated by environmental factors potentially associated with
developmental outcomes (Roberts et al. 1998). This model
also suggests, consistent with our findings, that children who
are otherwise at risk are most likely to be negatively impacted
by recurrent OM.
Implications for Policy, Delivery, or Practice: We
recommend that pediatricians prioritize high-risk children with
recurrent otitis media for developmental surveillance. We also
recommend that early childhood educators and early
intervention service providers maintain contact with
pediatricians when working with developmentally delayed
children with medical problems including recurrent otitis
media.
Primary Funding Source: HRSA, Foundation and corporate
funders
●Health and Mental Status of Families in New York City
Domestic Violence Shelters
Roy Grant, MA, Lourdes Lynch, Ph.D., Sharon Joseph, M.D.,
Irwin Redlener, M.D.
Presented By: Roy Grant, MA, Director of Research, Policy,
The Children's Health Fund, 215 West 125th Street, New York,
NY 10027; Tel: 212-535-9400; Fax: 212-535-7699; Email:
rgrant@chfund.org
Research Objective: There are many studies exploring the
impact of exposure to domestic violence (DV) on children. DV
exposure has been associated with emotional and behavioral
problems and with cognitive and speech-language deficits.
Fewer studies have been published on the health status of
children exposed to DV. The present study is intended to
describe the health and mental status of families recently
exposed to a level of DV sufficiently severe to have led them to
enter the city DV shelter system for safety.
Study Design: Our method was retrospective review of
electronic health records, noting key health conditions and all
behavioral health diagnoses for 316 pediatric patients (mean
age, 49 months; 57% male) and 203 adult patients (mean age,
26 years) who were mothers of pediatric patients.
Immunization status was determined by review of all patients
19-35 months old (N=71). Where possible we linked children
included in the data analysis to health data for their mother.
We compared prevalence of key indicators for this population
with the results of our recent study of a random sample of
homeless children (N=520) and of homeless mothers
(N=200) in city family shelters.
Population Studied: All were patients during 2004 of the
New York Children’s Health Project, a service of The
Children’s Health Fund. All families were domiciled in city DV
shelters. Services were delivered in a comprehensive family
practice medical home model, with mental health services
(psychological assessment, short-term treatment, case
management, referrals for ongoing services) co-located with
primary care. The patients were 63% African-American, 32%
Hispanic, 4% white, 1% other.
Principal Findings: For children, asthma prevalence was 27%;
anemia (<36 months) 14%; otitis media (<24 months) 24%;
obesity (BMI=>95th percentile, 6 years and older) 26%.
Compared to homeless children, these rates were lower,
although to a statistically significant degree only for otitis
media (p<.05). Prevalence rates were consistently higher than
typical and consistent with documented racial-ethnic
disparities. Ninety percent were up-to-date for immunization,
significantly higher than for homeless children (p<.01). Also
significantly higher (p<.01) was the rate of developmental and
behavioral problems among the children, with 43% diagnosed.
The mothers had less acute and chronic illness than homeless
mothers. Obesity (BMI=>30) was 28%, significantly lower
than homeless mothers (p<.01), and 52% had a psychiatric
diagnosis, significantly higher than homeless mothers (p<.01).
Of children linked to a parent in the adult data base (N=205),
50% had a mother with a psychiatric diagnosis; 35% had a
mother diagnosed with depression. Maternal depression was
significantly associated with child developmental and
psychiatric diagnoses (p<.01). For children under 6 years old
with a depressed mother, 32% were developmentally delayed
and 21% had a psychiatric diagnosis.
Conclusions: Children in domestic violence shelters,
compared to children in homeless family shelters, appear to
be in better health. Asthma and obesity rates are high. They
have more diagnosed developmental and emotional
problems. A contributing factor appears to be maternal
depression. Their mothers have a high rate of psychiatric
disorders.
Implications for Policy, Delivery, or Practice: Primary care
for families exposed to DV should include co-located mental
health services. Developmental surveillance and early,
preventive intervention are strongly recommended for these
children.
Primary Funding Source: HRSA, Foundation and corporate
funders
●Does being Fat Prevent a Fat Paycheck?
Euna Han, M.P.H., Edward C. Norton, Ph.D.
Presented By: Euna Han, M.P.H., Ph.D. candidate, Health
Policy and Administration, University of North Carolina at
Chapel Hill, McGavran-Greenberg Hall, Cb#7411, Chapel Hill,
NC 27799; Tel: 919-914-6591; Email: eunhan@email.unc.edu
Research Objective: The purpose of this study is to
understand how obesity affects the types of jobs chosen.
Although previous literature has linked obesity to labor
outcomes, such as wages and employment probability, the
effect of obesity on the likelihood of having a job where
slimness rewards has not been studied well.
Study Design: This study used two-stage estimation
techniques to identify the effect of obesity on types of job.
Body-mass index (BMI) was used to measure the extent of
obesity. We generated a dummy variable representing
occupations where slimness rewards using list of jobs where
social skills or relationship to people (inclusive of mentoring,
negotiating, instructing, supervising, diverting, persuading,
speaking-signaling, serving) is required, using the Dictionary
of Occupational Titles (DOT) and Occupational Information
Network (O*NET). The likelihood of having a job where
slimness rewards was assessed separately by gender as a
function of BMI. We specified an over-identified first-stage
equation to instrument individual BMI using exogenous statelevel variation in per capita sales of food stores and
restaurants. A Heckman selection model was used to control
for the selection into the labor force with state-level identifying
instruments including unemployment rate, number of
business establishments, and number of Social Security
Program beneficiaries. Repeated observations allowed us to
control for individual fixed effects.
Population Studied: The data are from the National
Longitudinal Survey of Youth 1979, which provides ongoing
panel information with a nationally representative sample of
12,686 young men and women. Respondents were 14 to 22
years old when first surveyed in 1979. We augmented the
publicly-available data by obtaining confidential geographic
information for individuals.
Principal Findings: An increase in BMI decreases the
probability of having a job where certain social skills or
relationship to people is required by 1.7 percentage points for
males and 3.7 percentage points for females, on average. The
instruments passed all the specification tests.
Obese people may be discriminated against by consumers
or employers due to their distaste for obese people.
Employers also may not want to hire obese people due to
higher expected healthcare costs if the employers provide
health insurance to their employees.
Conclusions: Slimness rewards in the labor market by
increasing the likelihood to obtain a job where social skills or
relationship to people are required, ceteris paribus.
Implications for Policy, Delivery, or Practice: Our study
results support the understanding of the economic cost of
obesity on labor market outcomes for an individual besides its
adverse effect on health. The spillover effect of obesity
increases the total cost of obesity to both individuals and
society as a whole.
Primary Funding Source: No Funding
●Does Psychiatric Comorbidity Increase Costs and Impact
Clinical Outcomes for Older Adults with Congestive Heart
Failure?
Nancy Hanrahan, RN, Ph.D., Steven Sayers, Ph.D., Ann
Kutney, RN, M.S.N., Sean Clark, RN, Ph.D., Brendali F. Reis,
Ph.D., Barbara Riegel, DNSc, CS, FAAN
Presented By: Nancy Hanrahan, RN, Ph.D., Assistant
Professor, Center for Health Outcomes and Policy Research,
University of Pennsylvania School of Nursing, 420 Guardian
Dr., Philadelpia, PA 19104; Tel: 215-573-6759; Fax: 215-573-2062;
Email: nancyp@nursing.upenn.edu
Research Objective: To estimate the rates of psychiatric
comorbidity of a sample of Medicare beneficiaries hospitalized
with heart failure and to examine the associations of
comorbidity to hospitalization risk, costs, and mortality.
Study Design: This is a cross-sectional study of prevalence of
treated psychiatric comorbidity in patients hospitalized in
1999 for CHF. A 5% national random sample of U.S. Medicare
beneficiaries was identified using the Denominator and
MedPar files from the Centers for Medicare & Medicaid
Services. Regression analyses associating psychiatric
comorbidity to outcomes were adjusted for the presence of
medical comorbidity.
Population Studied: Medicare beneficaries diagnosed with
heart failure, 65 years and older, and hospitalized in 1999 in
the United States.
Principal Findings: The prevalence rates of psychiatric
comorbidity in this sample hospitalized patients with CHF
was 11.82%. Depression had the highest rate of any specific
psychiatric disorder (6.24%). On average, any form of
psychiatric comorbidity was associated with one additional
hospitalization and an addition $7,500 - $11,000 in
hospitalization costs over a 1-year period. Both alcohol and
depression were associated with close to 3 additional
hospitalization days per stay. Only psychosis was associated
with an increase in mortality risk in this sample.
Conclusions: Psychiatric comorbidity is common and
significantly impacts economic and clinical outcomes in
hospitalized patients with CHF. This burden, although
significant, is probably underestimated because psychiatric
illness is known to be underdetected in hospitalized persons.
Implications for Policy, Delivery, or Practice: Future
research should examine the potential to reduce length of
hospitalizations, rehospitalization, and hospitalization costs
by addressing role of psychiatric comorbidity in patients with
CHF.
Primary Funding Source: No Funding
●The Relative Role of Social and Economic Factors on
Utilization of Mental Health Services by Medicare HMO
Enrollees with Depression
Jeffrey Harman, Ph.D., Stefanie A. Thompson, M.P.H.
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: Only about a third of older people with
depression receive adequate treatment. The objective of this
study is to assess the relative role of social factors and
economic factors on the probability of receiving depression
treatment by elderly Medicare HMO enrollees with
depression.
Study Design: Survey data were combined with health plan
claims data and used to estimate logistic regression models
to assess the role of social and economic variables on the
probability of receiving any depression treatment during a
year. Two social factors were measured and included in the
model: perceived social support and religiosity. Perceived
social support was measured by the Medical Outcome Study
Social Support Index (MOS-SSI). Religiosity was measured
using the objective and intrinsic subscales of the Duke
Religion Index (DRI). The economic variable included was
perceived financial burden and was measured by endorsement
of the statement "I can't make ends meet". The independent
variable was an indicator variable coded as 1 if the individual
either filled an antidepressant prescription during the year,
had a visit to a mental health specialist, or a visit to a general
medical provider with a recorded diagnosis of depression and
coded as 0 otherwise.
Population Studied: The study sample is derived from a
random sample (n = 5000) of Medicare managed care
enrollees aged 65 and older in a single health plan operating
in Florida’s Pasco, Pinellas and Hillsborough Counties
(Tampa/St. Petersburg area). Enrollees were contacted by
phone and asked to take a depression screen (PHQ-9).
Enrollees who consented to take the screen (n=682) and
screened positive for depression (a score of 10 or more
representing moderate to severe depression, n=90), were
asked to take an in-depth in-person interview and give consent
to access their healthcare claims. This resulted in a final
sample size of 68 persons.
Principal Findings: Perceived social support approached
statistical significance (OR=0.57, p=.10), suggesting that the
greater the level of social support, the lower the probability
that the individual would receive depression treatment.
Neither objective religiosity (OR=0.98, p=.86) nor intrinsic
religiosity (OR=1.04, p=.72) were significantly associated with
receiving depression treatment. However, enrollees with high
levels of perceived financial burden were over 10 times less
likely to receive any treatment for depression (OR=0.07, p =
.03) than enrollees who feel more financially secure. Overall,
after controlling for age, gender, race, and marital status,
adding perceived financial burden to the model increased the
explained variation by 58% while adding both the DRI
subscales and the MOS-SSI measure only resulted in a 4%
increase in the explained variation.
Conclusions: Although this study has limited sample size,
our findings show that economic considerations play a much
more significant role in the decision to receive depression
treatment by Medicare managed care enrollees with
depression than social factors.
Implications for Policy, Delivery, or Practice: In order to
improve treatment rates for depression in this population,
health plans and Medicare policies should focus on reducing
the out-of-pocket costs of obtaining depression care.
Primary Funding Source: National Institute of Mental Health
●Socio-Demographic Factors and Neighborhood
Characteristics as Correlates of Walking for Transportation
and Leisure in California Adults
Theresa Hastert, M.P.P., E. Richard Brown, Ph.D., Susan
Babey, Ph.D.
Presented By: Theresa Hastert, M.P.P., Research Associate, ,
UCLA Center for Health Policy Research, 10911 Weyburn Ave.,
Suite 300, Los Angeles, CA 90024; Tel: (310) 794-2827; Fax:
(310) 794-2686; Email: thastert@ucla.edu
Research Objective: To examine the relationship between
sociodemographic factors and neighborhood characteristics
and walking for transportation and leisure in California adults.
Study Design: We used data from the 2003 California Health
Interview Survey (CHIS), a random-digit dial (RDD) telephone
survey of 42,000 households drawn from every county in
California. Bivariate and multivariate analyses were used to
examine the relationship between family and neighborhood
characteristics and walking for transportation and leisure.
Population Studied: Responses of over 42,000 adults
interviewed for CHIS 2003.
Principal Findings: In a given week 27% of California adults
do not walk for at least 10 minutes for either transportation or
leisure. More adults walk for leisure (56%) than for
transportation (44%), and sociodemographic and
neighborhood factors influence these two types of walking
behaviors differently. Adults with high household incomes
(300% FPL and above) walk the most for leisure (76 min/wk),
while those with the lowest household incomes walk the most
for transportation (85 min/wk). Latinos walk the most for
transportation (72 min/wk) and Native Americans and Whites
walk the most for leisure (95 min and 77 min, respectively).
Neighborhood characteristics also affect walking. Adults with
a safe park within walking distance and those whose
neighborhoods have a crime prevention program or a
neighborhood watch walk more for leisure than those who do
not, but access to safe parks and crime prevention programs
do not impact walking for transportation. Adults who indicate
that their neighborhoods have high social cohesion walk more
for leisure and less for transportation compared to those
reporting low neighborhood social cohesion. In multivariate
analyses, the amount of time spent walking for transportation
was related to income and to race/ethnicity but not to
neighborhood characteristics. Latinos, Asians and adults with
incomes below the poverty threshold walk more for
transportation. In contrast, amount of time spent walking for
leisure was related to income, race and ethnicity, having
access to a safe park, neighborhood social cohesion, and
having a neighborhood crime prevention program. Latinos,
Asians, African Americans, adults with lower family incomes,
those with no access to a safe park, those reporting low
neighborhood social cohesion and those with no
neighborhood crime prevention program spend less time
walking for leisure.
Conclusions: Sociodemographic and neighborhood
characteristics impact the extent to which adults walk for
transportation and for leisure.
Implications for Policy, Delivery, or Practice: Walking is
only one form of physical activity, but for many adults, walking
is the only form of exercise they get. Improving neighborhood
safety and social cohesion and increasing access to parks may
encourage adults to spend more time walking and be more
physically active.
Primary Funding Source: RWJF
●Rates of Maternal Depression Before, During, and After
Pregnancy
Mark C. Hornbrook, Ph.D., Patricia M. Dietz, DrPH, M.P.H.,
Selvi B. Williams, MD, M.P.H., William M. Callaghan, MD,
M.P.H., Donald J. Bachman, MD, M.P.H., Evelyn P. Whitlock,
MD, M.P.H., F. Carol Bruce, M.P.H.
Presented By: Mark C. Hornbrook, Ph.D., Chief Scientist,
Center for Health Research, Kaiser Permanente Northwest,
3800 North Interstate Avenue, Portland, OR 97227-1110; Tel:
503-335-6746; Fax: 503-335-2428; Email:
mark.c.hornbrook@kpchr.org
Research Objective: Our aim is to understand the prevalence
of maternal depression with respect to timing related to
pregnancy—before, during, or after. Our secondary aim is to
examine antidepressant medication use, mental health visits,
and specialty area where depression was first recorded.
Maternal depression negatively affects quality of life, marital
relationships, mother/child bonding, and infant behavior and
development. Estimates of maternal depression’s prevalence
range from 7% to 24%, and while many studies focus on
postpartum depression, little research has focused on preexisting maternal depression and depression that emerges
during the pregnancy.
Study Design: Electronic medical record and administrative
data were used to identify pregnancies and diagnosed
morbidities before, during, and after the pregnancies. To be
included in the study, pregnant women had to have
continuous health plan eligibility for the full data collection
period. We examined depression diagnoses for three
periods—the 39 weeks prior to the index pregnancy, during
pregnancy, and the 39 weeks post-partum.
Population Studied: We identified women who were
members of an integrated healthcare delivery system between
January 1, 1998 and December 31, 2001, who had at least one
pregnancy resulting in live birth; for women with more than
one pregnancy, we selected the first complete pregnancy
during the study period. Diagnosis of maternal depression
included an ICD-9-CM depression diagnosis code or antidepressant medication dispensed during 30 days following the
code for mental disorders specific to pregnancy (648.4).
Principal Findings: Among 4,398 women with eligible
pregnancies, 15.4% (678) had a depression diagnosis before,
during, and/or after pregnancy. The prevalence of diagnoses
was 8.7% before, 6.9% during, and 10.4% after pregnancy. Of
women with diagnoses before pregnancy, 56.4% were also
had diagnoses during, and 53.4% had diagnoses after. Of
women with diagnoses during pregnancy, 65.6% also had
diagnoses after pregnancy. Of women with diagnoses
postpartum, 54.2% had diagnoses either before or during
pregnancy. Among women who had an indicator for
depression during any time period, 74.9% were dispensed
antidepressant medications. Antidepressant dispensings were
lowest during pregnancy. Most women had their depression
first recorded in primary care (41.7%), followed by mental
health (31.4%), Ob-Gyn (13.4%), and other departments
(13.4%). Depression was diagnosed most frequently by
primary care clinicians before and after pregnancy, and by OBGyn clinicians during pregnancy. We found no evidence of
pediatricians diagnosing postpartum depression.
Conclusions: Over half of the depression diagnosed
postpartum occurred among women with depression
diagnoses before or during pregnancy. This suggests that
depression diagnosed during the postpartum period may not
be a unique condition, but rather a chronic condition
exacerbated at a unique period in a woman’s life.
Implications for Policy, Delivery, or Practice: Maternal
depression is of sufficiently high prevalence that it should
receive high priority in women’s health programs. Moreover,
the transition from primary care to OB-Gyn and back to
primary care gives rise to increased opportunities for
discontinuities of care. Quality assurance efforts should focus
on systems interventions to ensure close communication and
coordination as the locus of care shifts during and after
pregnancy.
Primary Funding Source: CDC
●Relationship Between Anxiety Symptoms and HealthRelated Quality of Life in Patients with Generalized Anxiety
Disorder
Mark C. Hornbrook, Ph.D., Dennis A. Revicki, Ph.D., Louis
Matza, Ph.D., Gregory N. Clarke, Ph.D., Nancy A.
Brandenburg, Ph.D.
Presented By: Mark C. Hornbrook, Ph.D., Chief Scientist,
Center for Health Research, Kaiser Permanente Northwest,
3800 North Interstate Avenue, Portland, OR 97227-1110; Tel:
503-335-6746; Fax: 503-335-2428; Email:
mark.c.hornbrook@kpchr.org
Research Objective: While generalized anxiety disorder
(GAD) significantly impacts patient health-related quality of
life (HRQL) and functioning, it is often not recognized and
treated effectively in primary care. Treatment is varied, and
little is known about the patterns of psychopharmacologic and
other treatments in community practice settings. This study’s
primary aim was to evaluate the effect of GAD and anxiety
symptom severity on the HRQL of primary care patients
diagnosed with GAD in an integrated healthcare delivery
system. By evaluating the relationship between treatment
patterns and HRQL for GAD patients, we will be able to
estimate potential HRQL improvements achievable through
adherence to practice guidelines.
Study Design: Clinical assessments were administered by
telephone and included the Hamilton Anxiety Rating Scale
(HAM-A). HRQL was assessed using the Quality of Life
Enjoyment and Satisfaction Questionnaire–Short Form (QLES-Q-SF), Sheehan Disability Scale (SDS), and SF-12 mental
and physical component summary scores (MCS, PCS). Three
assessments were performed three months apart. This paper
presents the results of the baseline assessment only.
Population Studied: Patients aged 18 years or older with
DSM-IV–diagnosed GAD were recruited from the membership
of an integrated healthcare delivery system. All patients
signed informed consent documents and agreed to participate
in this six-month longitudinal study.
Principal Findings: A total of 132 patients (78% of whom
were women) were enrolled, with a mean age of 47.5 ± 13.9
years. At baseline, mean HAM-A score was 16.8 ± 7.6
(suggesting the presence of moderate anxiety symptoms);
mean Q-LES-Q-SF was 46.2 ± 8.7; mean PCS was 44.4 ± 9.9;
mean MCS was 44.4 ± 7.3, and mean SDS was 12.9 ± 7.6. At
baseline, HAM-A scores were correlated - 0.29 (p < .001) with
MCS, - 0.43 (p < .001) with PCS, - 0.57 (p < .001) with Q-LESQ-SF, and 0.36 (p < .001) with SDS scores.
Conclusions: These results indicate that GAD-related
symptoms, as measured by the HAM-A, were moderately
correlated with measures of HRQL and disability, reduced
physical function, and role impairment. Anxiety symptoms
reported by GAD patients may be significantly associated with
increased impairment to HRQL and functional outcomes.
Treatment patterns of patients with diagnosed GAD should be
monitored closely to ensure compliance with evidence
guidelines and to reduce unnecessary suffering.
Implications for Policy, Delivery, or Practice: This study
demonstrates the need for improved GAD treatments because
it imposes marked reductions in HRQL. Our previous
analysis of administrative claims data revealed that the
treatment patterns for GAD are varied and most patients
continue on medication therapy for less than three months.
Interventions are needed to assist primary care physicians in
recognizing, diagnosing, and treating GAD; to assist primary
care physicians in managing patient adherence to prescribed
treatments; to increase patient understanding of the benefits
of adherence to treatments that require longer duration to
achieve full therapeutic effectiveness; and to reduce anxietyrelated barriers to seeking help.
Primary Funding Source: Pfizer, Inc.
●Provider Knowledge, Beliefs, and Clinical Systems Use
are Associated with Improved Tobacco Guideline
Compliance Among Low-Income, Minority Populations
Dorothy Hung, Ph.D., M.A., M.P.H., Donna R. Shelley, M.D.,
M.P.H.
Presented By: Dorothy Hung, Ph.D., M.A., M.P.H., Research
Scientist, Sociomedical Sciences, Columbia University,
Mailman School of Public Health, 722 W. 168th Street, Suite
526B, New York, NY 10032; Tel: (212) 342-0154; Fax: (212) 3429097; Email: dh2237@columbia.edu
Research Objective: Tobacco use is the leading cause of
mortality in the U.S. Yet a 1997-2000 National Ambulatory
Care Study found that only 17% of smokers visiting a physician
in the past year were offered assistance and medication was
utilized in 6.8% of visits. This research describes correlates of
provider compliance with each of the 5 “A”s recommended by
the Public Health Service (PHS) guideline for addressing
tobacco use. Additionally, the study will be the first to
compare the impact of paper versus electronic chart systems
on tobacco-related practice patterns in primary care.
Study Design: Self-administered surveys were conducted
among healthcare providers from community health clinics
serving low-income, minority populations in NYC. Data
collection is currently underway, with an estimated final study
sample of approximately 1000 respondents. Preliminary
results are based on a 90% response rate among surveyed
providers.
Population Studied: Primary care physicians, nurse
practitioners, physician assistants, and registered nurses
serving high-risk populations.
Principal Findings: Of surveyed providers, 24% asked
patients about tobacco use, 50% advised smokers to quit, and
23% assessed smokers’ readiness to quit. For patients who
were ready to quit, 3% of providers prescribed
pharmacotherapy, 17% referred patients to cessation
programs, and 9% arranged follow-up for tobacco use.
Knowledge of PHS guidelines was associated with increased
prescription of tobacco pharmacotherapy and arrangement of
follow-up in person or by phone (p<0.05). Belief that tobacco
cessation is part of a provider’s role, and beliefs regarding
effectiveness/confidence in helping tobacco users quit were
positively associated with asking about tobacco use, advising
patients to quit, assessing readiness to quit (p<0.10), and
prescribing tobacco pharmacotherapy (p<0.05). Routine use
of clinical systems was positively associated with ascertaining
tobacco use (p<0.01). Compared to physicians, registered
nurses were less likely to ask (p<0.001), advise (p<0.05), and
assess (p<0.05) tobacco use. Final results from the full
sample and comparisons of paper versus electronic chart
system effects on practice patterns will be presented.
Conclusions: Despite recent evidence-based guidelines, this
study finds that providers treating high-risk patients do not
address tobacco use regularly. Controlling for barriers such as
time constraints, preliminary results suggest that increasing
provider knowledge of evidence-based treatment strategies
can enhance tobacco cessation activities. Furthermore,
reinforcing the provider’s role in intervention and
implementing clinical systems may facilitate comprehensive
“5A” care processes. Lastly, the PHS recommends greater
involvement by multiple provider types, as this has been
found to increase abstinence rates. This study suggest that
nurses in community health clinics can be utilized more
effectively to aid initial steps of tobacco identification and
assessment of readiness to quit. This may prompt and allow
physicians more time to appropriately prescribe medications
or refer smokers to tobacco specialists.
Implications for Policy, Delivery, or Practice: This research
has important implications for reducing health disparities in
tobacco use. Continued efforts are needed to disseminate
guidelines and implement health systems and organizational
policies to improve tobacco identification and treatment
among high-risk populations. Findings also suggest
restructuring provider roles and implementing a team
approach to more effectively address patient tobacco use.
Primary Funding Source: NYSDOH
●Influence of Practice and Provider Attributes on
Preventive Service Delivery
Dorothy Hung, Ph.D., M.A., M.P.H., Thomas G. Rundall,
Ph.D., Benjamin F. Crabtree, Ph.D., Alfred F. Tallia, M.D.,
M.P.H., Deborah J. Cohen, Ph.D., Helen A. Halpin, Ph.D.
Presented By: Dorothy Hung, Ph.D., M.A., M.P.H., Research
Scientist, Sociomedical Sciences, Columbia University,
Mailman School of Public Health, 722 W. 168th Street, Suite
526B, New York, NY 10032; Tel: (212) 342-0154; Fax: (212) 3429097; Email: dh2237@columbia.edu
Research Objective: Changing lifestyle behaviors such as
cigarette smoking, physical inactivity, unhealthy dietary
practices, and excessive alcohol intake is believed to have the
greatest potential for decreasing morbidity and mortality. This
research examines the influence that both practice and
provider attributes have on the delivery of preventive services
for health behaviors. Specifically, recent research indicates
that organizational attributes such as staff participation in
decision making can influence performance. Because primary
care practices are complex organizations, theories such as the
contingency perspective on decision making are informative,
and suggest the need for more focused attention on the
interactive/moderating effects of organizational attributes.
Study Design: This study used data collected from the
Prescription for Health initiative sponsored by the Robert
Wood Johnson Foundation. Quantitative data on 52 primary
care practices and 318 healthcare providers were gathered
from AHRQ practice-based research networks (PBRNs).
Hierarchical linear modeling was used to examine
associations between both practice and provider attributes
and preventive service delivery.
Population Studied: Primary care practices; Primary care
providers.
Principal Findings: Practice staff participation in decisions
regarding quality improvement, practice change, and clinical
operations positively influenced the effect of work
relationships on service delivery (p<0.01). Staff participation
negatively influenced practices of increasing size (p<0.01),
though clinics with higher staff participation delivered more
preventive services than those with lower participation levels
at any given practice size. Nurse practitioners and allied
health professionals reported more frequent delivery of
services compared to physicians (p<0.05). Lastly, use of
reminder systems and patient registries were positively
associated with preventive service delivery (p<0.05).
Conclusions: This study finds that staff participation in
practice decisions enhances the association between good
work relationships and preventive service delivery. This may
indicate that participation inherently fosters increased staff
ownership or “buy-in” of clinical goals and activities. Findings
also suggest that encouraging staff participation is most
beneficial in smaller practices or in small groups and teams,
and supports the “microsystem” as an important unit of
decision making and healthcare delivery. Large practices also
have the potential to improve quality by creating
microsystems of care within their broader infrastructures.
Additionally, this study provides evidence for the effectiveness
of allied health professionals in delivering preventive care,
which may reflect their greater time availability or training
emphasis in prevention. Findings suggest that practices can
leverage clinical staff and enable physicians to focus on other
medical issues by shifting preventive care roles and
responsibilities to other qualified healthcare providers. Finally,
this study reinforces recommendations for the use of
organized systems to improve care processes for prevention.
Implications for Policy, Delivery, or Practice: Policy and
practice implications are that staff participation in decisions
regarding quality improvement, practice change, and clinical
operations is a positive aspect of teamwork and collaboration
in small practices and groups. Policy makers and practice
managers might also consider leveraging non-physician
clinical staff and organized clinical systems to improve the
delivery of preventive services for health behaviors.
Primary Funding Source: RWJF
●Community Mental Health Service Interventions in
Slovakia: Impact on Hospital Lengths-of-Stay and ReHospitalization for the Severely and Persistently Mentally
Ill
Jenny Hyun, M.P.H., Petr Nawka, M.D., Joan Bloom, Ph.D.,
Soo Hyang Kang, DrPH, Ladislav Ocvar, M.D.
Presented By: Jenny Hyun, M.P.H., Doctoral Student, Health
Services and Policy Research, University of California Berkeley,
140 Warren Hall, c/o Bloom Research, Berkeley, CA 947207360; Tel: 510-540-9556; Email: jhyun@berkeley.edu
Research Objective: Reform of psychiatric services in Eastern
Europe has focused on shifting away from psychiatric
hospitalizations toward building infrastructure for the delivery
of community mental health services. Community mental
health services were introduced incrementally to severely and
persistently mentally ill (SPMI) individuals residing in the
Michalovce region of Slovakia beginning with in 2001. This
study seeks to assess the impact of community mental health
service interventions (i.e., case management, sheltered
housing, and psychiatric rehabilitation centers) on inpatient
lengths-of-stay for SPMI individuals in the Michalovce region
of Slovakia.
Study Design: This study uses a natural experiment design on
a cohort of SPMI individuals over five years. OLS regression
analyses were used to analyze the impact of community
mental health services on hospital lengths-of-stay.
Additionally, logistic regression analyses were used to assess
the probability of re-hospitalization within 30-days of
discharge. Analyses controlled for differences in demographic
and diagnostic characteristics between those who did and did
not receive community mental health services.
Population Studied: Analyses are conducted on a cohort of
802 SPMI individuals residing in the Michalovce region who
were hospitalized in 2001 at the psychiatric hospital in
Michalovce (n=4,010). One hundred seventy-two individuals
within the cohort received some type of community mental
health service intervention between 2001 and 2005. Those
who received community mental health services were more
likely to be younger, unmarried, and to have a diagnosis of
schizophrenia than those who did not receive community
mental health services. Mean lengths-of-stay were 159.1
(s.d.=134.5) and 58.5 (s.d.=86.7) days for SPMI individuals who
received community mental health services and those who did
not, respectively.
Principal Findings: Those SPMI individuals who received
community mental health services had 100.9 more days in the
hospital over the five-year study period than those who did not
receive community mental health services (p<0.01). Those
with a diagnosis of schizophrenia had 39.5 more hospital days
than those with other psychiatric diagnoses (p<0.01). While
lengths-of-stay decreased over time, the interaction of
community mental health services and time showed a
significant effect in 2004 and 2005 where those who received
community mental health services showed 60.8 and 85.7
fewer days of hospitalization, respectively, as compared to
those who did not receive community mental health services.
Those who received community mental health services were
significantly more likely to be re-hospitalized within 30 days
(OR=8.57, p<0.01), but their odds of 30-day re-hospitalization
decreased significantly in later periods.
Conclusions: Community mental health services are effective
in reducing hospital lengths-of-stay and re-hospitalization for
SPMI individuals. SPMI individuals who received community
mental health services had lower hospital lengths-of-stay and
were less likely to be re-hospitalized within 30 days in later
years of the study period.
Implications for Policy, Delivery, or Practice: This study
supports the continuing policy initiative of building deinstitutionalized, community-based mental health systems in
Eastern European countries. Future research should
investigate the cost-effectiveness and quality of community
mental health services, including implementation and
management of those services, as well as quality of life issues
surrounding de-institutionalized care for SPMI individuals.
Primary Funding Source: National Institute of Health
●Is Community Stabilization as Effective as
Hospitalization for Children with a Mental Health Crisis?
Neil Jordan, Ph.D., Julie B Eisengart, MA, John S Lyons, Ph.D.
Presented By: Neil Jordan, Ph.D., Assistant Professor,
Psychiatry & Behavioral Sciences, Northwestern University,
710 N Lake Shore Dr Ste 1205, Chicago, IL 60611; Tel: (312)
503-6137; Fax: (312) 503-0425; Email: neiljordan@northwestern.edu
Research Objective: For children with a mental health crisis,
there are two common treatment options. Psychiatric
hospitalization is a restrictive and intensive treatment that has
been shown to reduce symptoms, but this decrease does not
necessarily persist over time. Current trends emphasize
stabilizing youth in crisis through community-based
treatment, a less restrictive and less expensive alternative.
Although some studies have attempted to compare the two
treatments, these studies have failed to address a key
methodological issue: youth who are hospitalized typically
experience a more severe crisis than youth who receive
community-based treatment. The objective of this study is to
assess differences in outcomes of crisis care after adequately
controlling for differences in crisis severity.
Study Design: This retrospective cohort study compares the
outcomes of a natural sample of youth whose mental health
crises were treated either in the hospital or in the community
through Illinois’ Screening, Assessment, and Supportive
Service (SASS) program. SASS providers collected
demographic data and completed mental health assessments
for each child at the beginning and end of the SASS episode.
The primary measure used was the Childhood Severity of
Psychiatric Illness (CSPI). The dependent variable was change
in CSPI score. The children in the study sample were sorted
into two groups: hospitalization (if the child was hospitalized
at any point during his/her SASS episode; n=1760) and
community stabilization (n=781). Because at baseline the
children in the hospitalization group had significantly worse
psychiatric symptoms than children who were stabilized in the
community, we used propensity score analysis to match the
groups on demographic and clinical variables.
Population Studied: The sample included all Illinois children
who received crisis assessment and treatment services via
SASS during fiscal year 2005 (n=2541). SASS services include
hospitalization authorization and ongoing monitoring of
children who need acute psychiatric inpatient services,
deflection services for children who do not meet admission
criteria, and post-hospitalization services.
Principal Findings: For the full sample, receiving intensive
community services was associated with statistically
significantly better outcomes (i.e., reduction in total CSPI
score) compared to psychiatric hospitalization (B=-0.664,
95% CI = [-1.344, -0.126], t=-2.06). In subgroup analyses,
hospitalization was associated with statistically better
outcomes for children with more severe crises than
community stabilization (B=1.989, 95% CI = [1.363, 2.594],
t=6.04). For children with less severe crises, intensive
community services were associated with statistically better
outcomes than hospitalization (B=-1.195, 95% CI = [-2.346, 0.017], t=-2.03).
Conclusions: Across all children and youth who received a
crisis assessment, intensive community services were
associated with overall better clinical and functional
improvement than hospitalization. This finding suggests that
the most expensive, intensive treatment is not necessarily the
best choice universally. However, children and youth with
more severe mental health crises were more likely to
experience a reduction in psychiatric symptoms if hospitalized
rather than stabilized in the community.
Implications for Policy, Delivery, or Practice: These findings
reinforce the value of risk assessment for children in crisis
prior to making the decision to hospitalize. Further research
is needed to determine the clinical cut-point at which
psychiatric hospitalization becomes a more effective
intervention than intensive community services.
Primary Funding Source: No Funding
●Availability of Smoking Cessation Medications in
Substance Abuse Treatment: National Data from the
Public and Private Systems
Hannah Knudsen, Ph.D., Lori J. Ducharme, Ph.D., Paul M.
Roman, Ph.D.
Presented By: Hannah Knudsen, Ph.D., Assistant Research
Scientist, Institute for Behavioral Research, University of
Georgia, 101 Barrow Hall, Athens, GA 30602-2401; Tel: (706)
542-6090; Fax: (706) 542-6436; Email: hknudsen@uga.edu
Research Objective: More than 70% of individuals seeking
substance abuse treatment are current smokers, making
treatment centers a potentially important site for the delivery
of smoking cessation services. Few data are available
regarding the availability of pharmacological approaches to
smoking cessation, such as nicotine replacement therapy and
bupropion-SR, in these settings. Little is known about whether
organizational characteristics are associated with
pharmacotherapy availability. The objectives of this research
are to identify the rates of availability of three
pharmacotherapies (the nicotine patch, nicotine gum, and
bupropion-SR) and to estimate the associations between
organizational correlates and the availability of these
medications.
Study Design: Data were collected during late 2002 to early
2004 via face-to-face interviews with 763 administrators of
specialty substance abuse treatment centers. Administrators
provided information regarding clinical services and
organizational measures. The present analyses focus on the
availability of three pharmacotherapies: nicotine patch,
nicotine gum, and bupropion-SR (e.g. Zyban®). Independent
variables include: center type (government-owned, publicly
funded non-profit, privately funded non-profit, and for-profit),
accreditation status, center size, center age, levels of care
offered (inpatient/residential-only, outpatient-only, mixture of
OP and IP/residential services), and access to physicians
(physicians on staff, physicians on contract, or no physician).
Population Studied: This research draws upon nationally
representative samples of 362 publicly funded and 401
privately funded substance abuse treatment centers. Eligible
centers were required to be based in the community and offer
at least a minimum level of care equivalent to structured
outpatient. Response rates of 80% and 88% were achieved
among eligible public and private centers.
Principal Findings: Rates of adoption for the nicotine patch,
nicotine gum, and bupropion-SR were 27.7%, 14.0%, and
21.5% among the public centers, and 47.7%, 27.5%, and 41.1%
among private centers; these differences were statistically
significant. Logistic regression analyses revealed these
differences largely reflected variation within the non-profit
treatment sector, specifically between publicly funded privately
funded non-profit organizations. For the two types of nicotine
replacement therapy, accredited centers were significantly
more likely than non-accredited centers to have adopted these
medications. Levels of care were also associated with
adoption, such that outpatient-only facilities were less likely to
offer these medications. Finally, centers with at least one
physician on staff were significantly more likely than centers
without physicians to have adopted these medications.
Conclusions: These national data suggest that considerable
rates of adoption of smoking cessation-related medications in
the private sector and less adoption in the public sector. The
adoption of these medications is associated with
organizational characteristics, including center accreditation,
levels of care offered, and availability of staff physicians.
Implications for Policy, Delivery, or Practice: The
differences in the availability of smoking cessation
medications between public and private non-profit providers
suggest that policymakers should consider how incentives to
treatment centers may enhance adoption of smoking
cessation services in the public sector.
Primary Funding Source: NIDA
●Improving Behavioral Health Care Quality and Reducing
Emergency Room Visits and Costs Associated with
Anxiety: A Randomized Controlled Study
Andrew Kolbasovsky, Psy.D., Leonard Reich, Ph.D.
Presented By: Andrew Kolbasovsky, Psy.D., Director, Mental
Health, HIP, 55 Water St, New York, NY 10041; Tel: (646) 4477231; Email: akolbasovsky@hipusa.com
Research Objective: The objective of this study is to
determine the effectiveness of a stepped care, case
management-based intervention to improve the quality of
behavioral health care provided to members treated for anxiety
disorders in the emergency room (ER) by improving the
coordination of behavioral health and medical care across
different settings and systems.
Study Design: Randomized control design
Population Studied: Plan members aged 18 and older, seen
in the ER for an anxiety disorder between 1/1/04 and 12/31/04,
maintaining insurance coverage for at least six months
following that ER visit were included in this study. The initial
ER visit for anxiety during the study’s time frame is referred to
as the “index ER visit.” ER visits for any psychiatric condition
in the six months following the index ER visit are referred to as
“post-index ER visits.”
Principal Findings: Results demonstrated that members
randomly assigned to receive the intervention had significantly
fewer post-index ER visits than members randomly assigned
to receive usual care. The 307 members receiving the
intervention had a total of 79 post-index ER visits (average =
0.26 post-index ER visits per member) while the 300 members
receiving usual care had a total of 117 post-index ER visits
(average = 0.39 visits per member). Members receiving the
intervention also incurred significantly lower post-index ER
costs. Over the course of the study, the intervention saved a
total of $14,590.14 in ER costs, with a $7.92 per member per
month savings realized by the Plan.
Conclusions: Results of this study demonstrate the ability of a
case management-based intervention to improve the quality
of behavioral health care provided to members presenting to
the ER with anxiety disorders by utilizing strategies to improve
access to outpatient care, foster communication between
providers across different settings, and to improve the overall
coordination of behavioral health and medical services.
Implications for Policy, Delivery, or Practice: This study
demonstrates the clinical utility and financial benefits of a case
management intervention that is inexpensive to institute and
can easily be replicated and adopted in a variety of different
settings and organizations. The results have impacted our
Plan’s policies, delivery, and practice, as the intervention is
now provided to members presenting to the ER for all
psychiatric conditions.
The predictive model created in this study is unique in that it
explains a high proportion of the variance yet utilizes only
information that can be obtained quickly and easily by
administrative means allowing for the practical and financially
feasible application of this model into practice in a variety of
organizations. Currently, the results of this study are already
being translated into policy and practice in our health plan.
Using the results of the predictive model, a risk score is
calculated for each member discharged from a hospital for a
psychiatric condition. Based on this score, risk stratifications
have been created with different levels of case management-
based interventions delivered to members based on their risk
score. This allows the Plan to direct the greatest amount of the
limited available resources to the members in greatest need of
services, while also delivering services of a lesser intensity to
members with less need.
Primary Funding Source: No Funding
●Measuring Cultural Competence in the Mental Health
HIV Services Collaborative
Lisa LeRoy, Ph.D., M.B.A., Giulia Norton, M.P.H.
Presented By: Lisa LeRoy, Ph.D., M.B.A., Associate, Health
Policy, Abt Associates, 55 Wheeler St, Cambridge, MA 02138;
Tel: 617-349-2723; Fax: 617-349-2497; Email:
lisa_leroy@abtassoc.com
Research Objective: There is growing recognition that
culturally competent services are necessary to alleviate welldocumented disparities in health care. However, measuring
cultural competence is a challenge. Only a few frameworks
exist for evaluating cultural competence, and fewer still apply
to mental health services. Our objective was to assess the
cultural competence of mental health services provided in the
Mental Health HIV Services Collaborative (MMHSC). To do
so we utilized the Health Resources and Services
Administration (HRSA) Indicators of Cultural Competence in
Health Care Delivery Organizations (2002) as our assessment
framework. The MMHSC Program comprises 20 communitybased organizations that provide mental health services to
HIV-positive clients in traditionally underserved, minority
communities across the US. These are difficult clients to
serve because of their severe clinical and behavioral
conditions as well as needs related to immigration, poverty,
and non-English language. A goal of the 5-year program was
to provide culturally competent services. To help meet this
goal each program had a Consumer Advisory Board that
provided feedback on services.
Study Design: Data was collected at the program and clientspecific levels. Site visits were conducted during the first,
third, and fifth year of the program and included interviews
with program staff as well as consumers in the program. At
the client level, clinical information was collected at baseline
by clinicians and satisfaction data was collected from clients
after at least 2 visits. Site visit data from the 3rd and 5th years
was coded and analyzed using NVIVO software. Survey data
were analyzed using standard statistical analysis. We
compared our data from the three sources to the relevant
indicators from the HRSA framework.
Population Studied: The population of approximately 1400
HIV-positive clients is 64% male, 52% African-American, 27%
Latino and 21% Caucasian and other races. Fifty-two percent
of clients have depressive disorder, 7% bipolar disorder and
5% schizophrenia). The remaining clients had adjustment
and anxiety disorders.
Principal Findings: The HRSA cultural competence
framework helped to explain the empirical data and led to an
assessment of specific aspects of the sites’ cultural
competence, while the qualitative and quantitative data
highlighted weaknesses in the framework that need to be
addressed. One weakness is that framework does not include
indicators and measures from the client’s perspective.
Conclusions: The HRSA framework provided a useful tool to
assess cultural competence of mental health services for HIV-
positive minorities. The framework can be refined and the
authors recommend specific measures for inclusion in future
studies. Our data demonstrated changes between the 3rd and
5th year of the program in recruitment and retention activities,
staff development in cultural competence, treatment settings
(expansion in non-traditional settings), communication
materials, and collaborations with other community
organizations – all in the interest of improving cultural
competence. Client satisfaction was relatively high in
domains related to cultural competence and a second wave of
data collection in April 2006 will allow us to compare client
satisfaction among sites that undertook specific practices to
achieve cultural competence.
Implications for Policy, Delivery, or Practice: Our modified
framework to assess cultural competence in mental health
services can be effectively utilized by providers in underserved,
minority communities.
Primary Funding Source: SAMHSA/Center for Mental Health
Services
●Care Manager Caseload Capacity and Activities: Time
Tracking Results from Two Depression Collaborative Care
Projects
Chuan-Fen Liu, Ph.D., John Fortney, Ph.D., Susan Vivell,
Ph.D., Karen Vollen, RN, William Raney, RN, Barbara Revay,
RN
Presented By: Chuan-Fen Liu, Ph.D., Investigator, VA Puget
Sound Health Care System (152), VHA, 1100 Olive, Suite 1400,
Seattle, WA 98101; Tel: (206)764-2587; Fax: (206)764-2935;
Email: Chuan-Fen.liu@va.gov
Research Objective: Collaborative care models involving
Depression Care Managers (DCMs) are clinically- and costeffective. DCMs follow protocols for patient assessment,
triage to specialty mental health, education/activation, and
follow-up of uncomplicated depression in primary care. This
study estimated DCM time allocation by activity for two
completely separate VA collaborative care projects – TIDES
(Translating Initiatives for Depression into Effective Solutions)
and TEAM (Telemedicine Enhanced Antidepressant
Management).
Study Design: DCMs tracked their time and activities on
spreadsheets for four weeks, and recorded each patient seen
in a depression registry. We measured time required for 1)
initial assessment/education calls; 2) follow-up calls; and 3)
patient-related contacts with other clinical providers. Within
the first two categories we assessed direct clinical contact time
compared to time spent on ancillary activities (e.g. chart
review, note writing, unsuccessful calls). We estimated
maximum panel size as the largest number of active patients
per DCM in the TIDES and TEAM patient registries.
Population Studied: TIDES was conducted in seven
outpatient clinics in three Veterans Integrated Service
Networks (VISNs), with one nurse DCM in each VISN. TEAM
was conducted in three rural Community-Based Outpatient
Clinics in one VISN with one nurse DCM.
Principal Findings: On average, initial assessment/education
required 73 and 75 minutes for TIDES and TEAM, respectively,
with slightly more time (40-38 minutes) spent on ancillary
activities than on direct patient contact (33-37 minutes).
Follow-up calls required 47-46 minutes, including 30-28
minutes for ancillary activities. Provider contacts accounted
for 5 minutes in TIDES and 2 minutes in TEAM per successful
patient contact. The maximum patient panel size per quarter
was 165 patients for TIDES and 143 patients for TEAM.
Conclusions: The similar DCM time allocations and panel
sizes across two studies and three VISNs suggest that the
results we found are valid under current VA conditions.
Reductions in DCM time spent on ancillary activities, however,
may be achievable through improved informatics and other
support for panel management. Such improvements should
be introduced and evaluated.
Implications for Policy, Delivery, or Practice: Clinical
managers and policy makers can use these results to estimate
DCM staffing requirements and appropriate panel sizes for
collaborative care for depression under current VA conditions.
Primary Funding Source: VA
●Treatment Progress and Patient Compliance in
Treatment for Alcohol Abuse
Mingshan Lu, Ph.D., Hsien-Ming Lien, Ph.D., Ching-to Albert
Ma, Ph.D., Thomas G. McGuire, Ph.D.
Presented By: Mingshan Lu, Ph.D., Associate Professor,
Department of Economics, University of Calgary, 2500
University Dr NW, Calgary, T2N1N4; Tel: (403)220-5488; Fax:
(403)282-5262; Email: mingshan01@yahoo.com
Research Objective: Understanding what factors affect
whether patients comply with their doctor’s recommended
therapeutic regime has long been an important agenda item
for both medical professionals and health policy. Traditionally,
noncompliance is regarded as an “irrational” behavior or at
least an action taken by misinformed patients. Increasingly,
studies are examining how non-personal factors, such as
doctor-patient interaction, influence compliance. Due to data
limitations, it is still unclear why patients do not follow
doctors’ recommendations, and when they do not, whether it
is a good or a bad thing. This paper examines the causal
relationship between treatment progress and patient
compliance.
Study Design: We hypothesize that, in deciding about
compliance, patients balance expected costs and benefits
during a treatment episode. A patient is more likely to follow
medical advice if doing so results in an expected net gain in
his welfare or health benefit. We exploit a unique data set of
alcohol abuse clients receiving outpatient treatment. Using
treatment records, we measure the client’s compliance by his
attendance at scheduled appointments. We measure a client’s
health progress by the clinician’s comments after each
attended visit. We test the effect of better progress on two
measures of compliance: dropping out of treatment and
missing the next scheduled visit.
Population Studied: The data for this study come from two
sources. The first is the administrative records from the Maine
Addiction Treatment System (MATS). MATS collected
information of clients enrolled in substance abuse programs
that received funding from the federal government or the state
of Maine between October 1, 1989 and June 30, 1995. The
second is a set of medical record abstracts of one thousand
MATS episodes, collected by a group of Boston University
researchers under the supervision of OSA representatives. The
records were randomly sampled from MATS episodes that
were diagnosed as alcohol abuse and treated on an outpatient
basis. Their clinical records were obtained directly from these
agencies and linked to the administrative records in MATS
through a parallel scrambling algorithm to maintain
confidentiality.
Principal Findings: Our results indicate that experiencing a
relapse in the previous visit increases the chance of dropping
out of the treatment program; making progress decreases the
chance. These findings hold even after controlling for
unobserved heterogeneity of the clients. Nevertheless, we did
not find evidence about how experiencing relapse or progress
affects the chance of missing a scheduled visit. This is likely
due to the fact that missing a scheduled visit is a much more
complex non-compliance behavior than dropping out of the
treatment, affected by many random factors. Our data do not
contain enough information for us to test what are the driving
forces behind the non-compliance behavior of missing a
schedule visit.
Conclusions: Our study suggests that treatment progress is
likely an important factor that influences patients’ compliance
decisions. The main contribution of this paper is that we
develop a framework to identify the causal relation between
patient compliance and treatment progress. While our
findings may be specific to alcohol abuse treatment, our
methods can be generalized to other health services,
particularly to treatment for chronic illness.
Implications for Policy, Delivery, or Practice: Our paper has
demonstrated the potential value of collecting information
about treatment programs and about services declined by the
patient, as well as those that are accepted.
Primary Funding Source: NIAAA, Alberta Heritage
Foundation for Medical Research, Institute of Health
Economics
●Out-of-Pocket Expenditures for Medical Care Use by
Adults with Major Depression: Does Insurance Parity
Exists?
Ithai Zvi Lurie, MA, Dorothy D. Dunlop, Ph.D, Larry M.
Manheim, Ph.D.
Presented By: Ithai Zvi Lurie, MA, Institute for Healthcare
studies, Northwestern University, 339 East Chicago Ave.,
Chicago, IL 60611; Tel: (312) 503-8815;
Email: i-lurie@northwestern.edu
Research Objective: The study explores issues related to
overall out-of-pocket expenditures and insurance parity for
major depression by examining three related questions. First,
do individuals with depression pay more in total and out-ofpocket expenses relative to individuals without depression?
Second, is there insurance parity in overall insurance coverage
between depressed and non-depressed individuals? And to
the extent overall parity does not exist, for what type of
medical services do depressed adults pay a higher or lower
share of out-of-pocket relative to non-depressed people?
Study Design: The study identifies individuals with (and
without) major depression using the Composite International
Diagnostic Interview-Short Form (CIDI-SF) from the 1999
National Health Interview Survey (NHIS). Using respondent
baseline (1999) demographic and health characteristics from
the , we follow adults aged 18-64 who also took part in the
Medical Expenditure Panel Survey (MEPS) of 2000 to
determine the out-of-pocket and total expenditure for both
groups. A propensity scoring match is used to control for
individual characteristics, including co-morbidities, we
estimate the mean difference in out-of-pocket (and total)
expenditures for the major depression group relative to the
comparison group (matched individuals without major
depression).
Population Studied: This study uses data from the NHIS who
answered the 1999 mental health supplement and were
selected to participate in the MEPS study: 2,553 non elderly
individuals. Individuals with major depression represent about
5% of the sample, consistent with other national studies.
Principal Findings: Individuals with major depression pay on
average about 28% of their total expenditure out-of-pocket
relative to 20% for individuals with out major depression.
Most of the difference in out-of-pocket expenditure for
individuals with major depression relative to individuals
without is due to a higher expenditure for prescription drugs.
Since on average the co-payment for prescription drugs is
higher than other services (40% relative to about 20% for
office base visits, for example) the higher use of prescription
drugs among individuals with major depression increases
their relative share of out-of-pocket expenditures. However,
the insurance parity (the share of out-of-pocket expenditure)
per service does not differ for individuals with major
depression compared with individuals without.
Conclusions: The higher share of out-of-pocket expenditures
for individuals with major depression is mainly due to a larger
total expenditure for prescription drugs and not because of
higher co-payments for services. We cannot reject the
hypothesis of insurance parity for each service i.e. depressed
and non-depressed individuals paying the same share out-ofpocket expenditures from total medical bill for similar services.
Implications for Policy, Delivery, or Practice: The wave of
“parity” legislation has targeted making health insurance
benefits similar between mental and physical health. However,
the main differences in economic burden for individuals with
major depression results from higher expenditures on
prescription drugs combined with higher co-payment for drug
benefits relative to other services.
Primary Funding Source: NICHD; NIAMS
schizophrenia diagnosis (ICD-9 codes 295.x, excluding 295.5)
in the index years (fiscal years 2002, 2003) without having had
a schizophrenia diagnosis in the prior 5 years. As veterans
may receive care from non-VA providers, we restricted the
analyses to patients with VA use in at least 3 of the 5 prior
years. 83,893 patients met study criteria in FY2002, and
82,873 in FY2003. New-onset patients were compared to
previously diagnosed patients. In addition, new-onset
patients were categorized as usual vs. late-onset, defined as
having new-onset at age 40 or later. Usual vs. late-onset
patients were compared in terms of demographics,
comorbidities, and health services utilization.
Population Studied: Veterans with schizophrenia who
received health services in the Veterans Affairs health care
system during fiscal years 2002 or 2003 and who received VA
services in at least 3 of the prior 5 years.
Principal Findings: In FY2002, there were 7051 patients with
new-onset schizophrenia (8.4%). In FY2003, 6572 patients
(7.9%) were identified. Eight percent of new-onset patients in
FY2003 had late-onset schizophrenia. Late-onset patients
generated substantially fewer health system expenditures
($14,966 vs. $18,788; p<0.001), as compared to younger newonset patients. Late-onset patients also had fewer annual
outpatient clinic visits (48.1 vs. 50.0; p<0.05) and inpatient
psychiatric days of stay (20.7 vs. 24.7; p<0.001).
Conclusions: New-onset cases represent a substantial
number of VA patients treated for schizophrenia. Results
suggest growing acceptance of late-onset schizophrenia
among VA clinicians. Patients with late-onset schizophrenia
generated fewer costs and appear to have less severe
psychiatric treatment needs than early-onset patients.
Implications for Policy, Delivery, or Practice: With excellent
information technology, the VA provides a unique context for
examining new-onset of schizophrenia and differences by age
at onset. Understanding the prevalence and service needs of
these subpopulations may inform mental health treatment
practices and policies.
Primary Funding Source: VA
●Understanding New and Late Onset Schizophrenia
Among Ongoing VA Patients
John McCarthy, Ph.D., M.P.H., Helen C. Kales, MD, Martha
Sajatovic, MD, Frederic C. Blow, Ph.D., Dilip V. Jeste, MD, ,
●Length of Stay for Clients of Long Term Residential
Substance Abuse Treatment Facilities
Bentson McFarland, MD Ph.D.
Presented By: John McCarthy, Ph.D., M.P.H., Research
Investigator, Serious Mental Illness Treatment Research and
Evaluation Center, US Department of Veterans Affairs, P.O.
Box 130170, Ann Arbor, MI 48113-0170; Tel: (734)7697100,x6253; Fax: 734-761-2617; Email: John.McCarthy2@va.gov
Research Objective: Few studies have examined the
characteristics, service needs, and treatment patterns of
patients with new-onset of schizophrenia. Moreover, although
late-onset schizophrenia (at age 40 or later) has been
intensely debated, existing studies have been limited to small
non-representative samples. Late-onset patients have been
characterized as having more “negative” symptoms
(withdrawal, avoidance) than “positive” (delusions,
hallucinations.) We examined the prevalence and correlates of
new-onset schizophrenia and we compared health system
utilization by age at onset.
Study Design: Data were drawn from the VA’s National
Psychosis Registry. We defined new-onset as having had a
Presented By: Bentson McFarland, MD Ph.D., Professor of
Psychiatry, Psychiatry, Oregon Health & Science University,
3181 S.W. Sam Jackson Park Road, Portland, OR 97239; Tel:
(503) 245-6550; Fax: (503) 494-1209; Email:
mcfarlab@ohsu.edu
Research Objective: To describe length of stay for clients in
publicly-funded long term residential substance abuse
treatment facilities and to examine correlations with facility
characteristics.
Study Design: Data on annual admissions and current client
counts plus funding arrangements came from the National
Survey of Substance Abuse Treatment Services (NSSATS)
which represents some thirteen thousand publicly funded
treatment facilities. Prediction equations were developed to
estimate mean length of stay from admissions and client
counts using the Alcohol and Drug Services Study (ADSS)
information on 46 residential facilities. ADSS collected record
review length of stay plus facility-level data about annual
admissions and current client counts. Equations were
validated using 20 residential facilities in the National
Treatment Improvement Evaluation Study (NTIES) and 26
programs in the Drug Services Research Study (DSRS).
Data were also obtained from Treatment Episode Data Set
(TEDS) records about admissions to publicly funded
substance abuse treatment programs.
Population Studied: The project focused on some 2,410
publicly-funded non-hospital non-detoxification long term
(greater than 30 days) residential rehabilitation substance
abuse treatment facilities which were chiefly (91%) privately
owned with the remainder owned by federal, state, local, or
tribal governments. Admissions to such programs rose from
113,000 in 1992 to 149,000 in 2003 (most recent TEDS year).
Principal Findings: As expected, estimated mean length of
stay was highly correlated with observed in the ADSS data set
used for estimation (R-squared = 0.66, p less than .0001).
Estimated mean length of stay was also highly correlated with
observed in the NTIES (R-squared = 0.33, p = .05) and DSRS
(R-squared = .51, p less than .001) validation data sets.
The average estimated mean length of stay for long-term
residential treatment facilities in NSSATS 2003 was 108 days.
Estimated mean length of stay varied markedly by state
ranging from 30 days to 224 days (p less than .0001). Client
severity (based on age at first use of primary substance from
TEDS data) had little correlation with state mean length of
stay estimates. On the other hand, estimated mean length of
stay did vary with ownership. Private facilities had estimated
mean length of stay of 112 days versus 73 days for federal,
state, local, or tribal programs. Within the private sector,
there was no difference in mean length of stay between forprofit and not-for-profit facilities. Adjustment for ownership
did not affect the variation among states. Other predictors of
estimated mean length of stay included managed care
arrangements (which lowered estimated mean length of stay
by 44 days) and acceptance of Medicare (which raised
estimated mean length of stay by 32 days).
Conclusions: Estimated mean length of stay in long term
residential substance abuse treatment varies markedly by state
and is also influenced by funding arrangements but seems to
have little correlation with client severity.
Implications for Policy, Delivery, or Practice: Length of stay
is an important quality of care measure for substance abuse
treatment programs. Funders of substance abuse treatment
would be well advised to appreciate the influence of financial
arrangements on length of stay.
Primary Funding Source: NIAAA
●Pediatrician Coordination of Care for Children with
Mental Illness
Susan Pfefferle, M.Ed., Ph.D., Jody Hoffer Gittell, Ph.D.,
Dominc Hodgkin, Ph.D., Grant Ritter, MA, MS, Ph.D.
Presented By: Susan Pfefferle, M.Ed., Ph.D., Heller School,
Brandeis University, 17 W. Haycock Point Rd, Branford, CT
06405; Tel: 617-281-2594; Fax: 203-222-6543; Email:
pfefferle@comcast.net
Research Objective: Given that children with mental illnesses
receive services across an array of service sectors, care
coordination is of critical importance. Coordination has been
shown to improve outcomes. The objective of this paper is to
ascertain state-level and organizational variables associated
with care coordination activities performed by primary care
pediatricians on behalf of children with identified mental
illnesses. This study examines the effects of organizational
and state level policy variables within the same model.
Study Design: Data for this study come from a survey of
primary care pediatricians. These data are used to explore
state-level and organizational variables associated with higher
levels of pediatrician coordination of care for children with
mental illnesses. A stratified random sample of 1500
members of a pediatric organization was used. The sample
was stratified by state, with 250 members chosen per state,
resulting in a non-proportional sample. After three mailings a
response rate of 61% was obtained. Pediatricians were
surveyed about their care coordination practices and about
organizational characteristics. State level data were gathered
from a variety of sources. The dependent variable is a five-item
scale for past month coordination contacts, constructed from
pediatrician responses to five questions about past month
care coordination behaviors of themselves and their staff. The
scale was computed by summing the number of past month
coordination contacts across the five questions. The
Cronbach’s alpha for the scale was .82. Multivariate OLS
regressions were performed for the continuous dependent
variable.
Population Studied: Primary care pediatricians randomly
sampled from six states (N=596).
Principal Findings: No state-level variables were associated
with pediatrician coordination behaviors. Report of a staff
person assigned to coordinate care increased past month care
coordination by eight contacts (p<.05). A regular mechanism
for case conferencing was associated with an increased past
month coordination of 8.5 contacts (p<.05). Having a person
in the practice whose job it was to screen children for mental
illnesses was associated with an increase of 17.68 past month
coordination contacts (p<.05). Pediatricians who screened
more also coordinated more frequently. Each percentage point
increase in past year screening corresponded to an increase in
.12 past month coordination contacts (p<.01). Having a
mental health practitioner in the practice was associated with
an increase in seven past month coordination contacts
(p<.05).
Conclusions: Coordinating mechanisms such as having a
person assigned to coordinate care for children with mental
illnesses and having a regular method for case conferencing
were associated with increased rates of care coordination by
pediatricians. Further study is warranted to explore individual
and patient level variables that may impact levels of mental
health care coordination by pediatricians.
Implications for Policy, Delivery, or Practice: Several of the
coordinating mechanisms we report on appear effective, and
represent structures that pediatricians might initiate without
undue burden. This information should be useful in planning
ways to increase care coordination for children with mental
illnesses who are seen in pediatric primary care.
Primary Funding Source: Fahs-Beck Fund for Research and
Experimentation
●Pediatrician Mental Health Screening
Susan Pfefferle, M.Ed., Ph.D., Dominc Hodgkin, Ph.D., Grant
Ritter, MA, MS, Ph.D.
Presented By: Susan Pfefferle, M.Ed., Ph.D., Heller School,
Brandeis University, 17 West Haycock Point Rd, Branford, CT
06405; Tel: 617-281-2594; Fax: 203-222-6543; Email:
pfefferle@comcast.net
Research Objective: Many children with mental illnesses go
unrecognized in pediatric primary care despite the recognition
of the high prevalence of children’s mental disorders. Routine
mental health screening in pediatric primary care does not
occur. The principle objective of this study is to determine
factors associated with increased mental health screening.
Study Design: This study used data from a survey of primary
care pediatricians to explore state-level and organizational
factors associated with increased mental health screening in
pediatric primary care. The dependent variables were past year
percentage of children screened for mental health issues and
use of a validated screening tool. OLS and logistic
regressions, correcting for non-proportional sampling, were
performed.
Population Studied: Pediatricians in six states were randomly
selected from a mailing list. Three survey mailings yielded 596
eligible respondents for a 61% response rate.
Principal Findings: Over 53% of pediatricians reported that
they made use of a validated tool for mental health screening.
Mean percentage of past year screening was 20%. Results of
the multivariate regressions showed that those pediatricians
who reported higher levels of care coordination also reported
higher rates of mental health screening (p<.05). Having a
person assigned to do screening (p<.05) and use of a
validated screening tool (p<.001) were also significantly
associated with past year screening rates. Pediatricians who
used educational materials on mental health screening and
billing for mental health related activities had higher rates of
past year mental health screening (p<.05). Pediatricians in
states that recommend a mental health screening tool for
Early and Periodic Screening Detection, and Treatment
(EPSDT) under Medicaid had higher rates of screening
(p<.05). These same pediatricians were also more likely to use
validated screening tools (p<.001). Female pediatricians were
less likely to use mental health screening tools (p<.05).
Pediatricians who used educational materials on identifying
and treating children with mental illnesses were more likely to
use a validated screening tool (p<.01). No organizational
factors were associated with screening tool use.
Conclusions: Both practice characteristics and state-level
factors are associated with higher rates of mental health
screening. Screening tools are making their way into pediatric
primary care practices. No practice characteristics were
associated with screening tool use. Pediatrician level factors,
such as education, and state recommendation of a screening
tool under EPSDT increased the odds of screening tool use.
Implications for Policy, Delivery, or Practice: Staff assigned
to complete mental health screening can be integrated into
pediatric practices without too much difficulty. Statewide
initiatives such as those for reimbursement for screening,
inclusion of mental health as part of EPSDT, or educational
initiatives for children’s mental health may be effective ways to
increase use of mental health screening tools and thus
improve screening rates.
Primary Funding Source: Fahs-Beck Fund for Research and
Experimentation
●Pediatricians and Child Mental Health: Factors Related
to Primary Care Treatment
Susan Pfefferle, M.Ed., Ph.D.
Presented By: Susan Pfefferle, MEd Ph.D., Brandeis
University, 17 W. Haycock Pt Rd, Branford, CT 06405; Tel: 617281-2594; Fax: 203-222-6543; Email: pfefferle@comcast.net
Research Objective: Pediatricians treat a substantial
percentage of children with mental illnesses. Studies have
examined patient and pediatrician level factors, such as
gender, physician education on mental health issues, patient
presentation, family preferences, and insurance status
associated with pediatrician treatment of children with mental
health diagnoses. The objective of this study was to examine
the state-level and organizational factors associated with
pediatrician rates of treatment for children with mental
illnesses.
Study Design: Data from a survey of pediatricians are used to
explore state-level and organizational factors associated with
increased rates of pediatrician treatment for children with
mental illnesses. A stratified random sample of 1337 members
of a pediatric professional organization from six states was
used. After three mailings a response rate of 61% was
obtained, yielding 596 eligible responses. Pediatricians were
questioned about their treatment of mental health problems,
the percentage referred to specialty care, demographics,
availability of mental health professionals, and practice
characteristics. Data on managed behavioral health carve-out
penetration were obtained from an American Managed
Behavioral Healthcare Association survey and data from
United Behavioral Health cross referenced with U.S. census
data. Multivariate OLS regressions were performed to
determine the variables associated with higher rates of mental
health treatment.
Population Studied: Pediatricians from Connecticut, Kansas,
New Hampshire, South Carolina, Utah, and Washington were
randomly selected from a mailing list of a pediatric
organization.
Principal Findings: On average, pediatricians reported
treating 40% of children they diagnosed with mental illnesses
themselves. Regression results found that pediatricians
working in multi-specialty practices and staff model health
maintenance organizations reported higher rates of mental
health treatment (both p<.05). Pediatricians who reported
past year use of educational materials on identifying and
treating children with mental illnesses also reported that they
treated a greater percentage of children themselves (p<.001).
In addition, pediatricians who used a validated mental health
screening tool reported higher rates of mental health
treatment (p<.001). Higher managed behavioral health care
carve-out penetration rate in the state was associated with
lower rates of mental heath treatment by pediatricians (p<.05).
Having a mental health practitioner in the practice was not
significantly associated with pediatrician rates of mental
health treatment. Pediatricians’ perceptions of the accessibility
of mental health professionals were not significantly
associated with their rates of mental health treatment.
Conclusions: Several organizational and state-level factors
were found to be significantly associated with rates of mental
health treatment provided by primary care pediatricians.
Proximity to mental health specialists and pediatrician
perceptions about the availability and accessibility of mental
health specialists were not significantly associated with
pediatrician mental health treatment rates. This finding may
be due to the great shortage of mental health specialists.
Managed behavioral health care carve out rate were
significantly associated with pediatrician rates of mental
health treatment.
Implications for Policy, Delivery, or Practice: Given the
shortage of mental health providers, continued education is
needed to assist pediatricians to feel comfortable treating
children with mental health problems.
Primary Funding Source: Fahs-Beck Fund for Research and
Experimentation
●Do Behavioral Health Conditions Trigger Transition of
Medicare Elderly and Disabled into Medicaid?
Marjorie Porell, MS, Daniel M. Gilden, MS, Joanna Kubisiak,
M.P.H.
Presented By: Marjorie Porell, MS, Vice President, JEN
Associates, 5 Bigelow Street, Cambridge, MA 02139; Tel: 617868-5578; Fax: 617-868-7963; Email: mporell@jen.com
Research Objective: This research examines conditions that
frequently precede transition to Medicaid in the Medicareeligible aged and disabled. The objective of the research is to
profile those diagnoses that are frequently seen in the aged
and disabled prior to Medicaid enrollment relative to nontransitioning beneficiaries.
Study Design: Diagnoses 13 to 18 months prior to transition
into Medicaid are identified and contrasted to those
conditions of Medicare beneficiaries who do not transition in
the same period based on age/sex adjusted odds ratios.
Population Studied: The study population is the 1998 to
2000 Medicare 5% national sample panel, including
administrative enrollment and claims data partitioned for the
aged and non-aged disabled.
Principal Findings: Behavioral health conditions are
consistently ranked among the top 25 most correlated with a
transition to Medicaid eligibility. The specific conditions vary
between the aged and disabled. For the aged the primary
diagnoses are senility-related conditions, which have been
associated with falls and injuries that often lead to Medicaid
financed nursing home care. For the disabled the top
diagnoses are related to behavioral health conditions present
in combinations with physical and/or other disabling
conditions.
Conclusions: Based on diagnostic profiles of transitioning
Medicare aged and disabled, behavioral health conditions
appear to trigger a move into Medicaid.
Implications for Policy, Delivery, or Practice: Why do
behavioral health conditions trigger transition of Medicare
elderly and disabled into Medicaid? Understanding the
underlying causes, whether driven by deficient Medicare
behavioral health benefits and/or cultural stereotypes', is
critical for designing public policy that can begin address
fragmented behavioral health care for the aged and disabled.
Primary Funding Source: State of Massachusetts EOHHS
●Integrating Mental Health into Health and Emergency
Management Preparedness Planning: Interdisciplinary and
Inter-authority Challenges and Solutions
Madeline Robertson, J.D., M.D.
Presented By: Madeline Robertson, J.D., M.D., Associate
Professor, College of Public Health, University of Oklahoma
Heaath Sciences Center, 801 NE 13th Street, Oklahoma City,
OK 73190; Tel: 405/271-2115 ext. 37076; Fax: 405/271-1868;
Email: Madeline-Robertson@ouhsc.edu
Research Objective: The purpose of this project was to
increase the availability of disaster mental health services by
improving the integration of such services into state health
and all-hazards preparedness planning. Significant barriers to
making such services available exist despite the billions of
dollars infused into public health for disaster preparedness.
Therefore, we undertook this research to identify the methods
of success a few states have had to assist those still struggling
to include mental health in existing preparedness planning.
Study Design: We employed several methods to gather
information, including web searches, written and telephone
requests for documents, and telephone interviews with health,
mental health, emergency management and state homeland
security authorities. We contacted all 50 states and the
District of Columbia for their health and emergency
management preparedness plans. We obtained and reviewed
29 state health department preparedness plans and 43 state
emergency management plans. States that refused to
provide us with their plans did so explaining that the plans
were confidential. Following our plan review, we conducted
telephone interviews with the health department officials
responsible for administration of the CDC and HRSA grants,
the emergency management officials responsible for
emergency response plans, and the mental health officials
responsible for the SAMHSA grants. To develop our areas to
examine, we reviewed the interview questions used in another
state level informal survey.18 Based on the written plans we
identified states that appeared to be realizing the greatest
degree of integration of mental health, and contacted
appropriate state government officials for interviews. We also
contacted some states that did not appear to have made
significant progress in mental health preparedness in order to
give our sample geographic and content diversity. Ultimately
we interviewed officials from the following states: NC, PA, SC,
VA, CA, MN, ID, TX, and OK. Eight out of nine of these states
had SAMHSA grants. In all, we conducted eighteen interviews
in nine states.
Population Studied: (1)State civil emergency
management/homeland security authorities responsible for
integrating mental health preparedness into all-hazards plans
(2)State health authorities responsible for integrating mental
health preparedness into all-hazards plans;
(3)State mental health authorities responsible for mental
health preparedness.
Principal Findings: Of the 29 health department plans, six
had no reference to any mental health preparedness, 12 briefly
referenced mental health in one paragraph or less, and 15 had
some significant inclusion of mental health preparedness,
either in the body of the plan or by way of inclusion of a
mental health preparedness plan “annex” or “attachment” to
the health department plan. Of the 43 emergency
management plans, 12 plans made no reference to any mental
health component, 23 made a brief reference to mental health,
and eight contained significant mental health preparedness.
Thus, at least half of the state plans reviewed have little to no
mental health integration with their respective health
preparedness plans and four fifths of those reviewed have
little to no integration with emergency management plans.
States reported a number of common barriers to the
integration of mental health preparedness. Limited human
and financial resource was a common theme. Specifically (1)
the under funding of mental health preparedness planning;
(2) the channeling of mental health preparedness funding
through health authorities that have discretion over mental
health allocations; (3) limited state budgets; and (4) high
employee turnover. From an organizational perspective, the
following were common complaints: (1) rigid bureaucratic
structures; (2) large numbers of local government entities
involved; (3) the low priority of disaster mental health even
within mental health; (4) the lack of clarity of roles and
responsibilities. Problems associated with the lack of relevant
education, such as (1) the failure to recognize the value of
mental health; (2) stigma associated with mental health; (3)
absence of federal guidance, particularly with respect to the
role of substance abuse services; (4) failures of various
disciplines to communicate with each other (e.g. mental
health and emergency management, mental health and public
health.) Furthermore, as time passes since a states last
disaster, energy for preparedness activities also wanes. States
authorities having success with the integration of mental
health into all-hazard and health preparedness planning had
more than 30 techniques they utilized to address numerous
barriers to integration.
Conclusions: Widespread dissemination of the successes a
few states are having with the integration of mental health into
health and all-hazards planning should assist those states still
struggling with the integration barriers.
Implications for Policy, Delivery, or Practice: There are a
number of positive implications for behavioral or mental
health from this study. First, access to disaster mental health
services could be significantly increased if disaster mental
health authorities utilize the suggestions contained herein for
integration of mental health into health and all hazards
planning described herein. Second, because disaster mental
health includes services to “normal” patients reacting to
abnormal events, expanding these services may be a step
toward de-stigmatizing mental health services generally.
Finally, the requisite education of first responders and nonmental health authorities regarding disaster mental health
suggested herein should broaden the public’s understanding
of the value of behavioral health.
Primary Funding Source: Centers for Disease Control and
Prevention, Public Health Practice Program Office
●A Comparison of Medicaid Medical Expenditures for
Diabetes, Cardiovascular Disease and COPD/Asthma for
Persons with Schizophrenia or No Mental Illness.
Ingrid B Rystedt, M.D., Ph.D., Aricca D. van Citters, M.S.,
William J. Peacock, M.S., Stephen J. Bartels, M.D., M.S.
Presented By: Ingrid B Rystedt, M.D., Ph.D., Post-Doctoral
Fellow, New Hampshire Dartmouth Psychiatric Research
Center, Dartmouth Medical School, 2 Whipple Place, Lebanon,
NH 03766; Tel: (603)448-3163 ext 1110; Email:
ingrid.rystedt@dartmouth.edu
Research Objective: Our goal was to explore medical
utilization, as reflected by medical expenditures, for persons
with schizophrenia. Specifically, we sought to compare
medical utilization among persons with schizophrenia and
persons with no mental illness, and to compare medical
utilization across several comorbid medical disorders.
Persons with schizophrenia have high medical comorbidity
and die, on average, ten years earlier than the general
population. Yet, there is a lack of research evaluating medical
expenditures for this population.
Study Design: This cross-sectional analysis compared
Medicaid claims for persons with schizophrenia and
comorbidities of diabetes, cardiovascular disease and/or
COPD/asthma to claims for persons with no mental illness,
matched on age, gender, medical diagnosis and severity. Permember per-year medical expenditures were compared using
non-parametric methods.
Population Studied: Our original population consisted of
2001 New Hampshire Medicaid beneficiaries, ages 18 years or
older, in the community with no dementia or developmental
disability. Three hundred and twenty-five persons with
schizophrenia and comorbid conditions of diabetes,
cardiovascular disease and/or COPD/asthma were matched
with 325 persons with no mental illness and comorbid
conditions of diabetes, cardiovascular disease and/or
COPD/asthma. The sample was primarily female, 57 percent,
and Caucasian, 96 percent, with an average age of 50 years.
Principal Findings: Total medical expenditures were
significantly higher for individuals with schizophrenia and
multiple diseases, compared to those with no mental illness:
Mann-Whitney U=-2.07, p=0.038. In contrast, there was a
trend toward lower medical expenditures among individuals
with schizophrenia and diabetes, compared to those with no
mental illness: Mann-Whitney U=-1.89, p=0.059. There were
no statistical differences in expenditures between individuals
with schizophrenia or no mental illness and cardiovascular
disease or COPD/asthma. There were significant differences
in total medical expenditures across the four medical
conditions. For both persons with schizophrenia and no
mental illness, individuals with diabetes had the lowest
expenditures, while individuals with multiple diseases had the
highest expenditures. Significant differences in expenditures
were also evident among inpatient, outpatient, physician, and
pharmacy services.
Conclusions: Despite the added complexity of caring for
persons with schizophrenia and medical illness, we found no
consistent differences in medical expenditures for persons
with schizophrenia and no mental illness. Persons with
schizophrenia and cardiovascular disease or COPD/asthma
received Medicaid reimbursable medical care to the same
extent as persons with no mental illness. Persons with
schizophrenia and multiple diseases received more intense
medical services whereas persons with schizophrenia and
diabetes may have received less intense services.
To our knowledge, this is the first study that compares
expenditures for several major medical disorders for persons
with schizophrenia and no mental illness. Further research is
needed to explore whether these findings are replicable in
other settings. In addition, evaluations of whether differences
in medical expenditures across disease categories are
primarily explained by differential intensity of monitoring and
management, or, that treatments for some conditions are
simply more expensive will inform longer-term initiatives to
provide optimal and cost-effective medical services for
persons with schizophrenia.
Implications for Policy, Delivery, or Practice: Increased and
sustained attention to the medical needs of persons with
schizophrenia may reduce premature mortality, future
expenditures and demands on state health care budgets.
Primary Funding Source: AHRQ, Center for the Evaluative
Clinical Sciences at Dartmouth and New Hampshire
Dartmouth Psychiatric Research Center, Dartmouth Medical
School, New Hampshire Bureau of Behavioral Health through
the Behavioral Health Policy Institute, NIMH, NARSAD
●Resource Use Associated with Alcohol-Related
Admissions through the ED by Older Adults
Shadi Saleh, Ph.D. M.P.H.
Presented By: Shadi Saleh, Ph.D. M.P.H., Assistant Professor,
Health Policy, Management and Behavior, State University of
New York at Albany, School of Public Health, 1 University
Place, Rensselaer, NY 12144; Tel: (518) 402-0299; Fax: (518)
402-0414; Email: ssaleh@albany.edu
Research Objective: This study aimed at evaluating resource
use, specifically changes and length of stay, associated with
alcohol-related admissions through the ED by older adults.
Study Design: A cross-sectional design. The study used data
extracted from AHRQ’s national hospital discharge database,
Healthcare Cost and Utilization Project (HCUP) State
Inpatient Dataset (SID. Inpatient databases for eleven states
including Iowa, California, Oregon, Wisconsin, Washington,
South Carolina, Maryland, New York, Arizona, Colorado and
Florida were obtained.
Population Studied: The target population of the study was
older adults who had an alcohol-related Ed admission. The
group was further divided into acute and chronic alcoholrelated admissions.
Principal Findings: The study results revealed that the
presence of a secondary alcohol-related diagnosis associated
with the top ten Clinical Classification Software (CCS)
diagnoses significantly increased resource use (by two to three
folds). The study also showed that alcohol-related admissions
had lower associated charges that other types of ED
admissions ($14,510 vs. $16,682, p<0.05). However, acute
alcohol-related admissions incurred higher charges than
chronic ones. On the other hand, average length of stay (LOS)
for chronic alcohol-related admissions was higher than that of
other admissions (6.1 vs. 5.8 days, p<0.05) with chronic
alcohol-related admissions having a longer LOS than acute
admissions.
Conclusions: Resource use associated with alcohol-related
admissions is significant, even when compared to other
chronic diseases.
Implications for Policy, Delivery, or Practice: Proper
linkages of hospitals to substance abuse treatment services
should be instituted and coupled with medical treatment to
reduce the societal burden of such a population and help
decrease readmissions associated with alcohol-related
problems.
Primary Funding Source: No Funding
●Medication and Behavioral Treatment of Adult AttentionDeficit/Hyperactivity Disorder in United States Ambulatory
Care from 1996 to 2003
Jayashri Sankaranarayanan, Ph.D., Susan E. Puumala, MS,
Christopher J. Kratochvil, M.D.
Presented By: Jayashri Sankaranarayanan, Ph.D., Assistant
Professor, Pharmacy Practice, College of Pharmacy, University
of Nebraska Medical Center, 986045 Nebraska Medical
Center, Omaha, NE 68198-6045; Tel: 402-559-5267; Fax: 402559-5673; Email: jsankara@unmc.edu
Research Objective: In the midst of evolving evidence, the
National Institute of Health Consensus has recommended
medication and behavioral treatment of adult attentiondeficit/hyperactivity disorder (ADHD). However,
comprehensive investigations of the diagnosis and treatment
at adult-ambulatory visits in the United States (US) are
absent. Our objectives were 1) to study national estimates of
adult ADHD diagnosis with and without comorbid mental
disorders and their treatment patterns at ambulatory visits in
United States by adults aged 18-years and older and 2) to
examine significant patient factors associated with ADHDmediation and/ or behavioral treatment.
Study Design: The study design was a retrospective analyses
of the National Ambulatory Medical Care Survey and the
National Hospital Ambulatory Medical Care Survey for a
combined 8-year period (1996-2003).
Population Studied: We examined national estimates of ICD9-CM (International Classification of Diseases, Ninth Revision,
Clinical Modification) diagnosed ADHD visits and National
Drug Code based treatment rates. We classified ADHD
medication as “at least one stimulant or atomoxetine” and
ADHD treatment as medication and/or behavioral. Using
SAS-callable SUDAAN ver 9.0.1, we determined 1) national
estimates and characteristics of ICD-9-CM (International
Classification of Diseases, Ninth Revision, Clinical
Modification) coded ADHD and non-ADHD mental-disorder
visits by adults aged 18-years and older, including National
Drug Coded medication and behavioral treatments at these
visits, and 2) significant factors associated with ADHDtreatment in multivariable models.
Principal Findings: A total 10.5 million projected ambulatory
ADHD visits accounted for 3.5% of 300 million adult mental
disorder visits. Increasing from year 2000, ADHD visits were
commonly by males, Caucasians, persons aged between 18
and 40 years, and receiving care in metropolitan areas from
psychiatrists. About 14% of ADHD visits without comorbid
mental disorders did not receive any ADHD treatment.
Depression was the predominant comorbid mental disorder
at sixty percent of ADHD visits with comorbid mental
disorder. At ADHD visits with mental co-morbidity versus
those without mental co-morbidity; behavioral (83%vs.46%),
antidepressant (66%vs.18%), and combined ADHDmedication and behavioral treatment (57%vs.36%) were
significantly more frequent than a single ADHD medication
(68%vs.76%) respectively. Adjusting for gender, age, and
geographic-region; ADHD visits with comorbid mental
disorders (odds ratio [OR], 6.5, 95%Cl, 3.5-12.4,p<0.05) and
self-pay insurance (OR, 2.7, 95%Cl, 1.3-5.7,p<0.05) were
significantly more likely to receive behavioral treatment while
those with non-private insurance including Medicare and
Medicaid were significantly less likely to receive an ADHD
medication (OR, 0.4, 95%Cl, 0.2-0.7,p<0.05) or any ADHD
treatment (OR, 0.2, 95%Cl, 0.1-0.5,p<0.05) relative to those
with private insurance.
Conclusions: The data show increasing numbers of ADHD at
US adult ambulatory visits in recent years. However,
conservative estimates suggest opportunities to improve
diagnosis and treatment of ADHD in US ambulatory care
practice.
Implications for Policy, Delivery, or Practice: There are
many implications for health policy. Education of primary care
providers to facilitate diagnosis and treatment of ADHD is
warranted. Another important health policy implication is to
consider the non-private insurance factors associated with less
likelihood of treatment and encourage payers to reduce
insurance barriers. Finally, the presence of mental comorbidity
at ADHD visits merit future research into complex
multimodal-treatments to advance clinically rational and
equitable treatment access in adult ADHD populations.
Primary Funding Source: No Funding
●Diagnoses of Unipolar Depression Following Initial
Identification of Bipolar Disorder: A Common and Costly
Incongruent Diagnosis
Jennifer Schultz, Ph.D., Michael Stensland, Ph.D., Jennifer
Frytak, Ph.D.
Presented By: Jennifer Schultz, Ph.D., Assistant Professor,
Economics, University of Minnesota Duluth, 165 SBE 412
Library Drive, Duluth, MN 55812; Tel: 218-726-6695; Email:
jschultz@d.umn.edu
Research Objective: Context: Individuals with bipolar
disorder are frequently undiagnosed or misdiagnosed in
medical practice. Sixty-nine percent of individuals with bipolar
disorder report being misdiagnosed at least once, most
commonly (60%) with unipolar depression.
Objective: To assess the rate of unipolar depression diagnoses
in patients previously diagnosed with bipolar disorder, and to
determine treatment costs for bipolar disorder patients with
and without incongruent unipolar depression diagnoses.
Study Design: Methods: Propensity scoring was used to
control for selection bias. Utilization was evaluated using
negative binomial models. Two-part models (logit and
generalized linear models) were used to analyze the
relationship between incongruent depression diagnoses and
health care costs. To specify the cost models, a variant of the
Park test was used to determine the appropriate GLM
distribution and link function. The gamma distribution with a
log-link function was used to estimate positive costs. Robust
standard errors were calculated using the Huber-White-type
correction for the variance-covariance matrix of the parameter
estimates. These estimates were used to get predicted costs
conditional on utilization.
Population Studied: This study used retrospective,
longitudinal claims data from a large commercial US health
plan. Inclusion criteria included: two bipolar diagnoses,
continuous enrollment for one year before and after first
bipolar disorder diagnosis, age 18-64, and a pharmacy benefit.
Patients with two unipolar depression diagnoses following
initial bipolar diagnosis were categorized as having
incongruent diagnoses of unipolar depression (IDD).
Principal Findings: Of 3,119 patients meeting inclusion
criteria, 857 (27.5%) had subsequent incongruent depression
diagnoses (IDD). These patients had 1.62 times more mental
health providers, 1.82 times more mental health inpatient
visits, and 2.47 times more mental health ER visits than other
patients. For 673 patients (76.5%), the provider giving the
depression diagnosis had not given the bipolar diagnosis.
More than 80% of the providers making the initial IDD were
mental health specialists and almost 60% of these mental
health specialists were psychiatrists. Annual per patient
treatment costs were significantly higher for those with
incongruent depression diagnoses ($12,594) than those
without ($9,405).
Conclusions: Annual treatment costs for depression are
generally half of those for bipolar disorder. If the depression
diagnosis had been the correct diagnosis from the beginning,
we would not expect to see the large cost increase. The large
increases in utilization indicate that treatment associated with
incongruent depression diagnoses was not as effective as
treatment that occurred in the absence of an incongruent
depression diagnosis. This is consistent with the majority of
IDD patients having true bipolar disorder and being
misdiagnosed with unipolar depression, causing suboptimal
treatment and poor outcomes. More than one quarter of
individuals diagnosed with bipolar disorder received
incongruent depression diagnoses within one year. Most
misdiagnoses appeared to arise from lack of continuity of
care.
Implications for Policy, Delivery, or Practice: Most
misdiagnoses appeared to arise from lack of continuity of
care. Observed increases in mental health inpatient and ER
utilization, and treatment costs suggest that interventions to
improve continuity of care could improve patient outcomes
and reduce treatment costs.
Primary Funding Source: Eli Lilly and Company
●Behavioral Health Care in Massachusetts: Comparison
between the MassHealth Behavioral Health Carve Out and
Managed Care Organizations
Donald Shepard, Ph.D., Matthew Neuman, MS
Presented By: Donald Shepard, Ph.D., Professor, Heller
School for Social Policy and Management, Brandeis
University, 415 South St., MS 035, Waltham, MA 02454-9110;
Tel: (781)736-3975; Fax: (781)735-3928; Email:
shepard@brandeis.edu
Research Objective: Since 1992 Massachusetts MassHealth
enrollees (those in Medicaid and certain other statesponsored health programs) who reside outside of
institutional settings and who are not also covered by
Medicare or private insurance must enroll in a managed care
plan. Currently, this plan can be either one of four Managed
Care Organizations (MCOs), or a combination of the state’s
Primary Care Clinician (PCC) Plan (for general health services)
and a “carve-out” for behavioral health care services (BHCS).
The MCOs face full financial risk for all services, while the
carve-out contract limits financial risk on service costs to 0.2%
of their costs. Believing that the MCOs were more efficient,
some state officials proposed terminating the carve-out and
transferring enrollees to MCOs for all services. The legislature
called a hearing to gather more input. While the carve-out has
been extensively studied, we are not aware of comparable
evaluations of the MCOs. To inform this policy debate, we
compared the carve-out and the MCOs on cost, access to care
and utilization of services.
Study Design: Massachusetts classifies MassHealth
managed care enrollees in four Rating Categories (RC) based
on Medicaid eligibility. These categories are good predictors
of need for BHCS. We obtained statistical and financial
reports by RC through the state Public Records Statute and
the organizations for state fiscal years (FY) 2004 and 2005.
Several special populations, such as youth of the Department
of Social Services, are managed almost entirely by the carveout. We generated comparable populations by excluding
these special populations and case mix adjusting the
remaining members by rating categories. We then calculated
access (based on the “penetration rate,” i.e., unduplicated
users of services as a percentage of total members),
utilization, and costs of BHCS per member per month
(pmpm).
Population Studied: In FY ’05, MassHealth average
enrollment was 616,000 of which 78% was in the lowest rating
category (Families and Children, RC-I). The carve-out served
51% of enrollees and the MCOs the remaining 49%.
Principal Findings: The MCOs served a population with less
need for BHCS, with 92% of MCO enrollees in RC-I compared
to 64% of carve-out enrollees. Access was higher in the carveout than the MCOs (e.g., for RC-I, 22% vs. 17%, respectively).
Although the carve-out had higher costs pmpm on an
unadjusted basis, after excluding special populations and
adjusting, pmpm costs were almost identical (i.e., $68.63 for
the carve-out vs. $47.62 for the MCOs in FY ‘04 and $77.39 vs.
$48.14, respectively in FY ‘05). In fact, the carve-out’s
adjusted pmpm costs were 0.1% lower in FY ‘04 and 1.3%
lower in FY ‘05 than the MCOs’ corresponding costs.
Conclusions: The carve-out provides BHCS to MassHealth
members at least as efficiently as the MCOs and should be
continued.
Implications for Policy, Delivery, or Practice: States should
require their contracted health management organizations to
make comparable risk-adjusted data on access, quality, and
costs available on a timely and accessible basis. Policymakers
should utilize risk-adjusted comparisons in examining
alternative care arrangements.
Primary Funding Source: Mental Health and Substance
Abuse Corporations of Massachusetts, Inc.
●Do Psychiatrists’ Views on Schizophrenia Treatment
Recommendations Vary with the Proportion of Minority
Patients in Their Practices?
Elizabeth A. Skinner, M.S.W., Donald M. Steinwachs, Ph.D.,
Maureen Fahey, M.L.A., Anthony F. Lehman, M.D., M.S.P.H.
Presented By: Elizabeth A. Skinner, M.S.W., Senior 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: Differences in prescribed treatments
between Caucasian and minority (particularly African
American) patients with schizophrenia have been
documented. Among explanations proposed is bias among
clinicians toward patients in various groups, which may be
influenced by training, experience, practice milieu, etc. Also,
less than half of patients with schizophrenia receive guidelineconsistent treatment, but the reasons for this gap are not
known. It may be that opinions about treatment guidelines are
influenced by the environments clinicians’ practice in,
including race/ethnicity of their patients. This study examines
views of practicing psychiatrists concerning five
recommendations for managing schizophrenia, and whether
those with more minority patients differ in opinions about
those recommendations.
Study Design: A mail survey of practicing psychiatrists
presented five 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: Practicing psychiatrists in Maryland were
surveyed, including all 61 psychiatrists in rural areas and a 1/3
random sample of the remainder (N=539). The response rate
was 53%. About 3/4 of respondents worked in direct patient
care and 60% in office-based practice; 166 had treated
patients with schizophrenia in the past year.
Principal Findings: The average percentage of minority
patients was 36.2%, and higher proportions were associated
with practice characteristics like less time spent in solo
practice, higher proportions of Medicaid patients and urban
location. Concerning their experience treating schizophrenia,
physicians with >60% minority patients were more likely to
rate as problems adherence to medications (mean 4.0 vs 3.5
on 5-point scale) and follow-up regimens (4.0 vs 3.4), family
member involvement (3.8 vs 2.8), and patient substance
abuse/dependence (4.1 vs 3.1). However, there was no
bivariate association between proportion of minority patients
and ratings of factors that might affect recommendation
adoption. We examined ratings of patient willingness to
accept care consistent with recommendations, ease of
implementation, effects on outcomes, adequacy of
compensation, and readiness to adopt, and none were
associated with patient race/ethnicity. This finding was largely
confirmed in multivariate analyses controlling for
characteristics of physicians (gender, race/ethnicity, years
since training), practices (solo practice time, outpatient unit
time, urban location) and patients (schizophrenia, self-pay,
Medicaid), and for ratings of problems in treating
schizophrenia. Exceptions concerned adjunctive treatment for
depression: psychiatrists with fewer minorities were more
likely to rate the recommendation as easy to implement and
acceptable to patients.
Conclusions: While psychiatrists’ assessments of problems
faced in the management of schizophrenia are associated with
patient race/ethnicity mix, this is generally not the case for
their views on schizophrenia treatment recommendations.
Implications for Policy, Delivery, or Practice: While
attitudes and perceptions may not match practices,
understanding factors influencing psychiatrists’ views of
barriers to the implementation of recommended treatments is
a first step in developing targeted interventions to help
clinicians bring their practices into greater concordance with
evidence-based guidelines.
Primary Funding Source: NIMH
●Behavioral Healthcare Service Use Implications of
Suicide Risk Factors among Depressed Young Adults
Eric Slade, Ph.D., Lawrence Wissow, M.D., Mark Weist, Ph.D.
Presented By: Eric Slade, Ph.D., Associate Professor,
Psychiatry, Univ. of Maryland and Dept. of Veterans Affairs,
737 W. Lombard St., Baltimore, MD 21201; Tel: 410-706-8469;
Fax: 410-706-0022; Email: eslade@psych.umaryland.edu
Research Objective: To explore how suicide risk factors
among depressed young adults relate to their use of
antidepressant medication and mental health and substance
abuse counseling. Suicidal behaviors among young persons
have recently received increased attention by media outlets
and have become the focus of large-scale research studies.
However, few reports have examined how suicide risks are
being addressed by U.S. healthcare providers. Background:
Here, we contend that even by comparison to other young
adults who are depressed, those at higher risk of suicidal acts
should have greater utilization of preventive behavioral
healthcare services.
Study Design: A secondary analysis of observational data
from a national probability sample of young adults. An index
of risk factors for a suicide attempt was included in
multivariate logistic regressions predicting use of
antidepressant medication and receipt of mental health or
substance abuse counseling, respectively. The index was
comprised of a count of up to five suicide-related problems:
frequent heavy alcohol use in the past year, history of sexual or
physical maltreatment during childhood, high impulsivity,
whether the individual had “seriously thought about
committing suicide” in the past year, and low self-esteem.
Additional covariates measured interactions between the risk
index and depression treatment and primary care visits. Other
factors affecting service use were also controlled in
regressions.
Population Studied: A representative national sample of
young adults aged 18 to 26 years with elevated depressive
symptoms.
Principal Findings: Each additional risk factor was associated
with about a 4.5-5.0 average percentage point increase in use
of antidepressant medication (P<.001) and counseling
(P<.001), indicating substantial positive effects of risk factors
on service use. Even so, only about half of respondents with a
medical history of depression treatment and a high number of
risk factors received medication or counseling in the prior
year. Compared to other individuals who also had a medical
history of depression treatment, those at higher risk were not
more likely to receive counseling (F =0.31, df1=1, df2=128,
P=0.581), were only marginally more likely to use
antidepressant medication (F=3.13, df1=1, df2=128, P=0.079),
and were more likely to have experienced unmet need for
psychiatric services in the prior year (chi-squared=13.27, df=2,
P=0.001). Additional analyses indicated that behavioral
disincentives to engagement in treatment (e.g., fear of
treatment) were more common among high risk depression
patients with unmet need than among lower risk depression
patients with unmet need (85% vs. 25%, chi-squared=6.54,
df=2, P=0.038).
Conclusions: Neither behavioral health nor medical systems
adequately support use of behavioral health care services by
young adults at high risk for suicidal acts.
Implications for Policy, Delivery, or Practice: Depressed
young adults who are at high risk for suicide may be more
likely to experience strong disincentives to engagement with
behavioral healthcare providers during times of acute need.
The viability and potential effectiveness of innovative
engagement and service delivery approaches emphasizing
patient safety and focus should be considered by states that
are pursuing service system transformation as well as in
future clinical research.
Primary Funding Source: No Funding
●Symptom Onset and Patterns of Service Use among
Youth with Conduct Disorder: Findings from the Great
Smoky Mountains Study
Leyla Faw Stambaugh, Ph.D., Barbara J. Burns, Ph.D., Gordon
Keeler, M.S.
Presented By: Leyla Faw Stambaugh, Ph.D., Postdoctoral
Fellow, Psychiatry and Behavioral Sciences, Duke University
Medical Center, Box 3454 DUMC, Durham, NC 27710; Tel:
919-687-4686 ext. 306; Fax: 919-687-4737; Email:
lstambaugh@psych.duhs.duke.edu
Research Objective: The overall aim of this project was to
document knowledge about service use for children with
conduct disorder (CD) up to age 13. Specific goals were to
examine (a) the rate of CD among youth in the community,
(b) rates of service use among children with CD, (c) patterns
of service use across sectors, and (d) demographic variations
in the findings.
Study Design: The Great Smoky Mountain Study is a
longitudinal, population-based study in western North
Carolina. Children aged 9, 11, and 13 were randomly selected
from school lists and screened for mental health
symptomatology. All high-risk and 10% of low-risk youth were
selected for the study. The final sample consisted of 1,398
youths interviewed over four annual waves. The Child and
Adolescent Psychiatric Assessment was used to measure
DSM-IV symptomatology. The Child and Adolescent Services
Assessment was used to measure service use for emotional
and behavioral problems.
Population Studied: Approximately half (50.7%) of the
sample were male. The racial distribution of the sample was
as follows: 69.3% White, 24.5% American Indian, and 6.2%
African American. Approximately 20% of the sample were
living in poverty.
Principal Findings: Service use across sectors was as follows:
Education (81.3%), Specialty Mental Health (61.8%), Child
Welfare (30.6%), and Juvenile Justice (10.4%). Child Welfare
services were utilized by a higher percentage of females
(41.9% vs. 27.9%).
Conclusions: Findings confirm earlier research showing early
onset of CD symptoms, and higher prevalence in boys.
Despite high rates of any service use prior to age 13, there was
a lag between symptom onset and access to services. Use of
multiple sectors supports findings on the multiple problems
often faced by these children and the heavy burden they can
incur on the system. High rates of service use in the
Education sector highlight the role of the school system in
supporting and triaging children with mental health problems.
Low rates of contact with Juvenile Justice may be related to the
young age range of the sample. Higher use of Child Welfare
among girls may relate to the higher rates of abuse that have
been reported in girls.
Implications for Policy, Delivery, or Practice: Findings
underscore a need for earlier screening and service provision.
Future work should also address the use of special education
services (e.g., special classes for learning disabilities,
behavioral handicap, and developmental disabilities) by boys
and girls with CD. Communication among sectors will also be
important as these children move within the system.
Primary Funding Source: NIDA
●Lower Health Care Costs in Medicaid Managed Care
Organization Enrollees Treated for Substance Abuse:
Incentive for Taking Action
Kenneth Stoller, M.D., Peter Fagan, Ph.D., Martha Sylvia, M.S.,
Michael E. Griswold, B.S., Pierre Alexandre, Ph.D., Linda J.
Dunbar and Robert K. Brooner, Ph.D.
Presented By: Kenneth Stoller, M.D., Assistant Professor,
Psychiatry and Behavioral Sciences, Johns Hopkins University
School of Medicine, 5510 Nathan Shock Drive, Suite 1500,
Baltimore, MD 21224; Tel: (410) 550-0039; Fax: (410) 5502957; Email: kstolle@jhmi.edu
Research Objective: Members of Medicaid managed care
organizations (MMCOs) with substance use problems (SUPs)
utilize high levels of medical services, and therefore represent
a population for which the MMCO incurs high health care
costs. The objective of present study is to evaluate the
association between SUPs, SUP treatment, health care
utilization and costs in a MMCO population.
Study Design: Paid claims data from a single MMCO in
Maryland for calendar year 2002 were used for preliminary
analyses of health care utilization and costs. Diagnostic codes
determined by the State Medicaid Agency were used to
categorize adult MMCO enrollees into groups with (n=4,569)
or without (n=40,584) SUP. The latter group was further
categorized as having receiving SUP treatment (one or more
paid claims for SUP treatment during the calendar year) or as
untreated.
Population Studied: The population consisted of all adults
enrolled in a MMCO (n=45,153) during calendar year 2002.
Principal Findings: Mean health care costs were higher in
2002 than in 2001. This cost increase was higher among
members with versus without SUP (16% increase vs. 7%
increase). Examination of 2002 data revealed that members
with SUPs incurred more than threefold higher health care
costs compared to members without SUPs ($1,320 versus
$416 per member per month). Members with SUPs who
received SUP treatment had an average total health care cost
that was 44% lower compared to those without SUP
treatment claims (Treated: $1,057 vs. Untreated: $1,885, per
member per month). This finding is consistent with the prior
analysis of 2001 data, and related to differences in the
incidence of inpatient medical admissions (Treated: 517 vs.
Untreated: 1,380, per 1000 members). The reduction in cost
more than offsets the expense of SUP treatment. Additional
analyses that will be completed and presented, including
diagnostic prevalence/incidence, as well as medical utilization
and costs further broken down by service category (e.g.,
inpatient, pharmacy, emergency care, SUP treatment). The
association between clinical features and utilization and costs
by treatment status will be examined and presented.
Conclusions: Preliminary data indicate that 1) MMCO
members with SUPs represent a high-cost population worthy
of further study and targeted interventions; and that 2) the
treatment of substance use problems is associated with lower
total health care utilization and costs than when SUPs remain
untreated.
Implications for Policy, Delivery, or Practice: These
preliminary analyses support: 1) MMCOs creating internal
systems that encourage SUP case-finding and treatment as a
method of cost containment (such systems have since been
instituted in this MMCO); and 2) State Medicaid agencies
creating incentives for MMCOs to increase SUP treatment
delivery. Subgroups of members with particular features (e.g.,
HIV status, age band, or gender) that may be found to have
more pronounced reductions in cost when SUP is treated can
form a basis for targeting interventions designed to encourage
SUP treatment entry.
Primary Funding Source: NIDA
●The Association between Level of Communication and
HIV Medication Adherence among HIV Patients in South
Carolina
Carleen Stoskopf, Sc.D., Jong-Deuk Baek, Ph.D., Yunho Jeon,
M.S.
Presented By: Carleen Stoskopf, Sc.D., Professor, Health
Services Policy and Managment, University of South Carolina,
800 Sumter Street, Columbia, SC 29208; Tel: (803) 777-3332;
Fax: (803) 777-1836; Email: cstoskopf@sc.edu
Research Objective: The objective of this study is to examine
the association of the level of communication between HIV
patients and their medical providers with HIV medication
adherence.
Study Design: This study is a secondary data analysis. The
data is gathered from 2000 to 2004 through the Supplement
to HIV/AIDS Surveillance (SHAS) project in five counties
(Richland, Charleston, Bamburg, Orangeburg, and Calhoun)
in South Carolina. The project implements interviews to
obtain supplemental information on HIV/AIDS patients who
have been reported through the state and local surveillance
system. From the data, patients were classified into one of two
groups, those with good communication regarding HIV
medications, and patients with poorer HIV medication
communication. This was accomplished using four survey
questions. Those patients that reported having gone to
someone for advice, information or help in taking HIV
medications were then asked from whom they sought
information. Of those 171 patients, 164 reported seeking
information about HIV medications from clinical staffs
(physician or nurse). Of those 164 patients, 154 reported that
they considered their physician or nurse to be the most useful
source of information on HIV medications. A fourth question
from the survey asks if the patient’s physician has discussed
HIV drug resistance with them. If patients answered “yes” to
the question on resistance and reported that their physician
and/or nurse were the most useful source of HIV medication
information, the patient is considered to have “good” clinical
communication. All others are classified as having poorer
clinical communication. Multivariate logistic regression is
employed to look at the impact of the communication level on
HIV medication adherence after controlling for variables that
are known to influence HIV medication taking behavior of HIV
patients. Control variables are selected by the Anderson’s
health care utilization framework and include predisposing
variables (gender, race/ethnicity, mode of exposure, and
education), enabling variables (employment, insurance, ADAP
and income), and needs variables (diagnosis category, CD4 T
cell, and health status).
Population Studied: Out of 874 HIV patients 423 are
screened as those taking HIV medication in the past 12
months at the time of interview. After data refinement, 307
observations are used for this analysis.
Principal Findings: The association between the
communication level and HIV medication adherence is
statistically significant after controlling for predisposing,
enabling, and needs variables. HIV patients who have better
communication with their medical providers are 2.424 times
more likely to adhere to their HIV medications in this sample
(95% Confidence Interval 1.390-4.228).
Conclusions: Better communication between patients and
clinical staffs leads to better medication adherence in HIV
patients.
Implications for Policy, Delivery, or Practice: Considering
various connection technologies in a practical setting and
developing interpersonal skills that facilitate communication
between medical providers and HIV patients are needed.
Better communication would lead patients to better adherence
to HIV medications prescribed, and thus improve patients’
lives and reduce transmission.
Primary Funding Source: No Funding
●Medication Behavior and Medication Costs Among
Americans with Depression and Pain: A National Study
Haijun Tian, Ph.D Candidate
Presented By: Haijun Tian, Ph.D Candidate, Doctoral Fellow,
Pardee RAND Graduate School, RAND Corporation, 1776
Main Street, Santa Monica, CA 90407; Tel: 310-699-7988; Fax:
310-260-8151; Email: tian@rand.org
Research Objective: To analyze the relationship between
depression and comorbid pain, and medication outcomes and
medication costs among Americans.
Study Design: Multivariate regression analyses, controlling
for socio-demographics and chronic health conditions,
estimated the associations between depression and pain, and
medication outcomes and medication costs. Outcomes
included: use of antidepressants, use of effective
antidepressants, use of St. John's wort, total medication costs,
prescription drug costs.
Population Studied: Cross-sectional data were used from
Wave 1 of Healthcare for Communities, a U.S. national
household survey conducted in 1997-1998.
Principal Findings: Compared to depression alone,
depression and comorbid pain was associated with much
higher total medication costs and prescription costs. (p<0.01).
The presence of comorbid pain did not influence the use of
any antidepressants, but reduced the likelihood of adherence
to the use of antidepressants.
Conclusions: Depression with comorbid pain, not depression
alone was responsible for a large part of the higher medication
costs associated with depression. Individuals with depression
and pain however are associated with lower rates of use of
medications for their depressive symptoms.
Implications for Policy, Delivery, or Practice: The depressed
with comorbid pain appear to experience greater burden
through increased medication costs and may require different
management than those with depression alone. The
depressed with comorbid pain may benefit from treatment
practices and guidelines that address the duality of these
conditions throughout the process of care.
Primary Funding Source: No Funding
●Patterns of Guideline- Consistent Depression Treatment
Among Veterens
Anjali Tiwari, M.D., MS, Mangala Rajan, M.B.A., Donald R
Miller, Ph.D., Leonard Pogach, M.D., M.B.A., Usha
Sambamoorthi, Ph.D.
Presented By: Anjali Tiwari, MD, MS, Coordinator
Datasystems, Center for health care knowledge management,
Veteran Health Administration, 385 tremont avenue, east
orange, NJ 07018; Tel: (973)676-1000-3376; Fax: (973)-3957114; Email: tiwari@njneuromed.org
Research Objective: Diabetes and depression are both very
common in patients served by the Veterans Health
Administration (VA), yet population-based studies that
address depression treatment in veterans with diabetes are
scarce. The need is most critical for studies assessing patient
and health care system level variation in treatment patterns for
depression in patients with diabetes. Our objective was to
estimate guideline-consistent depression treatment among
veterans with diabetes, measure its variation in the VHA, and
examine its association with patient level factors.
Study Design: We conducted a retrospective episode-of-care
analysis of using VHA data and Medicare data for VHA clinic
users with diabetes. Incident episodes of depression were
identified based on a 120-day “negative diagnosis and
medication history” on or before the first observed depression
diagnosis date. Guideline-consistent depression treatment
was defined as the administration of anti-depressants for at
least 90 days after the onset of depression. Major depression
was identified using ICD-9-CM codes (296.2, 296.3, 298.0,
300.4, 311). Chi-square tests and logistic regression analysis
were used to assess guideline-consistent depression
treatment.
Population Studied: The study population included 42,199
VHA clinic users diagnosed with diabetes and major
depression in fiscal year (FY) 2000, who were alive at the end
of FY2001.
Principal Findings: Overall, 3,712 VHA diabetes patients had
an incident episode of major depression between Feb 1st 2001
and Apr 30th 2001in FY 2001. Of these, 34% received
guideline consistent treatment for depression. African
Americans were less likely than whites to receive guidelineconsistent depression treatment after adjusting for age,
gender, marital status, and co-morbidity (Odds ratio= 0.78, p=
0.01)
Conclusions: African Americans were less likely to receive
guideline consistent treatment.
Implications for Policy, Delivery, or Practice: These findings
suggest the need to treat depression more aggressively
among veterans with diabetes.
Primary Funding Source: VA
●State-by-State Mental Health Services and Expenditures
in Medicaid, 1999
James Verdier, J.D., Ann Cherlow, Jeffrey Buck, Ph.D.
Presented By: James Verdier, JD, Senior Fellow, Research,
Mathematica Policy Research, Inc., 600 Maryland Ave., SW,
Suite 550, Washington, DC 20024-2512; Tel: (202) 484-4520;
Fax: (202) 863-1763; Email: jverdier@mathematica-mpr.com
Research Objective: To determine service use and
expenditures for Medicaid beneficiaries with and without
mental health (MH) diagnoses on a state-by-state and
national basis, using newly available Medicaid Analytic eXtract
(MAX) data files for 1999. Nine tables for each state and the
nation show services and expenditures by beneficiary age, sex,
race/ethnicity, Medicare-Medicaid dual eligible status, and
eligibility group (aged, disabled, adults, children). We also
assess the completeness and quality of the 1999 MAX data in
each state for the measures used in the study, and rate each
state’s MAX data on a 1 (poor) to 4 (good) scale.
Study Design: To prepare the tables, we used MAX
administrative enrollment and claims payment data files for 50
states and the District of Columbia that were created by the
Centers for Medicare & Medicaid Services in 2002. We
identified the “MH population” by whether the beneficiary had
a claim for payment in 1999 showing as a primary diagnosis
one of 17 MH diagnoses, or received one of three types of MH
institutional care.
Population Studied: All Medicaid beneficiaries who had one
or more months of fee-for-service (FFS) coverage in 1999.
Months in which beneficiaries were enrolled in capitated
managed care arrangements were excluded because of lack of
data. While enrollment in capitated managed care varies
widely among states and Medicaid eligibility groups, nationally
72 percent of Medicaid beneficiaries were in FFS care for at
least one month in 1999 and FFS services accounted for 76
percent of total expenditures.
Principal Findings: The MAX data are a major resource for
studies of Medicaid service use and expenditures across
states, especially for states and populations with limited
managed care enrollment. Studies of beneficiaries with
specific diagnoses can also be done with the MAX files,
although only limited diagnostic information is available for
dual eligibles because most of their acute care services are
paid for by Medicare. While the results of our analyses cannot
be released until they have been cleared by SAMHSA, we
expect clearance in time for the conference. We will be able to
report comparative state-by-state measures such as the share
of Medicaid enrollment and expenditures accounted for by the
MH population, average annual days of general inpatient care
per MH user for MH vs. non-MH services, average annual
number of emergency room visits for MH vs. non-MH
beneficiaries, use of psychotropic drugs by MH vs. non-MH
beneficiaries, and use of specific types of psychotropic drugs
by MH beneficiaries with specific MH diagnoses.
Conclusions: There are major differences in the use of
Medicaid services between those with and without MH
diagnoses and among states. Some of the differences are
related to capitated managed care enrollment and the quality
and completeness of Medicaid administrative data in specific
states, which we assess in this study.
Implications for Policy, Delivery, or Practice: This study is
the first that has reported Medicaid MH service use and
expenditures for all 50 states. The MAX files, now available for
1999-2002, provide a starting point for developing
standardized state-by-state reports on Medicaid service use
and expenditures for beneficiaries with MH and other
diagnoses.
Primary Funding Source: Substance Abuse and Mental
Health Services Administration
●Care-Seeking Experiences Among Vietnam Veterans at
Varying Levels of Risk for Suicide
Katherine Virgo, Ph.D., M.B.A., Jennette R. Piry, M.Ed., Darcy
R. Denner, BS; Mary P. Valentine, B.D.S., M.P.H., Nathan K.
Risk, MA, Gery Ryan, Ph.D., Rumi Kato Price, Ph.D., M.P.E.
Presented By: Katherine Virgo, Ph.D., M.B.A., Professor,
Surgery, Saint Louis University & St. Louis VAMC, 3635 Vista
at Grand Blvd., Saint Louis, MO 63110-0250; Tel: (314) 2897023; Fax: (314) 289-7038; Email: virgoks@slu.edu
Research Objective: Identify and compare the types of
patient-based and system-based barriers and facilitators
experienced by Vietnam veterans at risk for suicide when
seeking care for physical, psychiatric, and substance abuse
conditions.
Study Design: This study is based on a longitudinal sample of
494 Vietnam veterans discharged from military service in
September 1971 and subsequently identified as at risk for
suicide (306 low risk; 188 high risk). Seventy-one percent (350)
of 494 participants completed an extensive qualitative and
quantitative interview covering, among other topics, physical
conditions, psychiatric conditions, substance use, barriers to
care, facilitators of care, and quality of care. Barriers and
facilitators were compared by type of condition and suicidal
risk category using chi-square analysis and Fishers as
appropriate.
Population Studied: The analysis is based on 262 interviews
(75 percent) with qualitative data transcribed thus far.
Principal Findings: Of the 195 patients with self-reported
health conditions, 76 (39.0 percent) and 45 (23.1 percent)
expressed self-imposed and system-based barriers to care,
respectively. The group at higher risk of suicide was
significantly more likely (p < .01) to report patient-based
barriers to care and system-based barriers to care (p < .05),
and more likely (p < .05) to experience negative effects of the
care-seeking experience. Patient-based, but not system-based,
facilitators of care were also significantly more likely among
high-risk patients.
Conclusions: Both self-perceived and system-based barriers
to care pose obstacles for patients at high risk of suicide.
Implications for Policy, Delivery, or Practice: Targeted
interventions are required to reach out to these patients to
address needs for care currently unmet by the health care
system and to reduce negative effects of the health care
experience.
Primary Funding Source: NIMH, NIDA
●Health and Health Behaviors: The Pathways That Link
Social Capital To Health.
Hongmei Wang, Ph.D. Candidate
Presented By: Hongmei Wang, Ph.D. Candidate,
Epidemiology and Public Health, Yale University, 154
Mansfield St, New Haven, CT 06511; Tel: (203)645-8254;
Email: Hongmei.wang@yale.edu
Research Objective: In recent years, a growing number of
health researchers have investigated the relationship between
social capital and individual’s health status. Social capital,
measured as either the density of social networks, general
trust in other people, or a combination of the two, has been
documented to be positively related to an individual’s health
status in developed countries. The estimated relationship of
social capital and health is relatively strong, compared to other
social determinants of health and well-being. However, the
study of social capital’s links to health is relatively new and
remains incomplete in several important ways. There is some
evidence that certain aspects of social capital may be more
consistently or substantially linked to some dimensions of
health than to others, but these differential effects remain
poorly understood. To better understand these possible causal
pathways, this paper examines different components of social
capital and their combined influences on different aspects of
health measures: physical health, mental health, and health
behaviors.
Study Design: This paper adopted multivariate ordered
logistic regression analyses, adjusting for survey design
effects, for main analyses. The outcome variables included a
5-point scale self-reported general health, a 3-point scale selfreported mental health measure, and a categorical health
behavior measure indicating smoking intensity. Social capital
was measured by 10 questions measuring both trust and
mistrust levels. A trust index and a mistrust index were
constructed and both measures were also aggregated at
village level for analysis. A rich set of variables including
demographic, health risk measures, social economics status
variables, and sanitary measures were controlled in the
models.
Population Studied: The analysis focused on rural residents
in two provinces in China who are 15 years to 85 years old.
The data employed was from the household survey of the
Rural Mutual Healthcare Project, jointly conducted by Harvard
China Health Policy Center and China Health Economics
Institute. The data was collected from Yunnan province and
Shanxi province in year 2002 using a stratified clustered
sample. The final sample for this paper consisted of 9608
participants.
Principal Findings: (1) Measured as interpersonal trust, both
individual-level social capital and village-level social capital
have a significant impact on health. Individual trust and
mistrust have opposite impact on a person’s health as
expected. (2) Social capital appears to impact on both
mental health and physical health, but to different degrees.
Mistrust has a more powerful influence on mental health
outcomes. (3) Village-level social capital is suggested to be
significantly associated with smoking behaviors of the village
residents. On the contrast, individual-level social capital does
not have significant association with smoking behaviors.
Conclusions: The empirical results appear to support the
conclusion of social capital influences health from both
individual-level and village-level in rural China. Second, this
study further suggests that different forms of social capital,
trust and mistrust, work together to influence health and they
impact differentially on various health outcomes and health
behaviors. Third, the magnitude of the estimated linkages
between health and social capital is large compared to other
social economic factors.
Primary Funding Source: No Funding
●Using Medications to Detect Treated Maternal
Depression
Selvi B. Williams, M.D., M.P.H., Evelyn P. Whitlock, M.D.,
M.P.H., Patricia M. Dietz, Dr.P.H., M.P.H., William M.
Callaghan, M.D., M.P.H., Donald J. Bachman, MS, Mark C.
Hornbrook, Ph.D.
Presented By: Selvi B. Williams, M.D., M.P.H., Research
Associate III, Center for Health Research, Kaiser Permanente
Northwest, 3800 North Interstate Avenue, Portland, OR
97227-1110; Tel: 503-335-3916; Fax: 503-335-2428; Email:
selvi.williams@kpchr.org
Research Objective: Depression affects maternal healthrelated quality of life, including marital relationships,
mother/child bonding, and infant behavior and development.
Identifying and treating this health problem is imperative.
Previous studies using administrative data have defined
depression to include dispensing of antidepressants, even in
the absence of depression diagnoses. Our aim was to
evaluate whether anti-depressant medications are prescribed
for medical conditions other than depression among women
before, during, and after pregnancy, and to ascertain whether,
and under what conditions, antidepressant medication
dispensings can be used as indicators of maternal depression.
Study Design: We identified pregnant women with
depression diagnoses. We also identified women who had at
least one antidepressant dispensing, but no depressionindicating diagnoses, during the 39 weeks before the
beginning of pregnancy, during the pregnancy, or during the
39 weeks after pregnancy. Medical records were reviewed for
a subsample of these women to detect medical indications for
antidepressants other than depression.
Population Studied: We identified women who were
members of a large integrated healthcare delivery system
between January 1, 1998 and December 31, 2001, and who had
at least one pregnancy resulting in live birth; for women with
more than one pregnancy, we selected the first complete
pregnancy during the study period. Diagnosis of maternal
depression included an ICD-9-CM depression diagnosis code
or anti-depressant medication dispensed within 30 days of the
code for mental disorders specific to pregnancy (648.4).
Principal Findings: Among 4,398 eligible pregnancies, 200
(4.6%) were associated with use of an antidepressant, but no
depression-indicating diagnosis. Among a subsample of 30
women who were dispensed tricyclic antidepressants, 67%
had diagnoses for chronic pain or migraine headache, and
23% had a diagnosis for another mental health disorder, such
as anxiety or premenstrual dysphoria syndrome. Among 10
women prescribed bupropion with no diagnosis indicating
tobacco use, 30% had a diagnosis for another type of mental
health disorder, and 30% for a headache or chronic pain.
Among five women who were prescribed bupropion and had a
diagnosis indicating tobacco use, we found no evidence that
the medication was prescribed for depression. Diagnostic
frequencies for other mental health disorders, chronic pain,
migraine headaches, and tobacco use are presented by type of
antidepressant medication.
Conclusions: Chronic pain, migraine headache, tobacco use,
and mental health conditions other than depression are
indications for antidepressant medications before, during, and
after pregnancy. Using anti-depressants alone as an indicator
of depression may lead to biased results in epidemiologic
studies ascertaining maternal depression.
Implications for Policy, Delivery, or Practice: Quality
assurance efforts are needed to improve documentation of
diagnoses of depression, especially when antidepressant
treatment is ordered and provided. Research on quality of
care measures should focus on completeness and timeliness
of maternal depression diagnosis.
Primary Funding Source: CDC
●Access Factors Associated with the Use of St. John's
Wort among Adults with Depressive Symptoms
Chung-Hsuen Wu, BA.Pharm.
Presented By: Chung-Hsuen Wu, BA.Pharm., Master Student,
Health Policy and Administration, Washington State
University, 2217 W. Pacific Ave Apt 208, Spokane, WA 99204;
Tel: 509-499-1252; Email: pmwu@ms2.hinet.net
Research Objective: To examine the association between the
access to conventional healthcare and the use of St. John’s
wort among adults who report depressive symptoms.
Study Design: Secondary analysis of the Complimentary and
Alternative Medicine supplement to the 2002 National Health
Interview Survey (NHIS).
Population Studied: Weighted prevalence rates were
estimated for users (sample, n=246) and nonusers (sample,
n=1030) of St. John’s wort who reported depressive
symptoms. Logistic regression modeling was used to identify
factors associated with use.
Principal Findings: Depressed people who delayed their
medical care because of the cost are more likely to use St.
John’s wort (27.3% vs. 18.9%, P=0.01). People who cannot
afford needed medical care (27.5% vs. 19.6%, P=0.02) or
cannot afford mental health care or counseling (19.7% vs.
30.0%, P=0.03) are more likely to use St. John’s wort than
those who can.
Conclusions: The growing use of complimentary and
alternative therapies in the U.S. is widely interpreted as
evidence of changing consumer tastes and dissatisfaction with
the conventional medical treatment for chronic conditions like
depression. However, the rising costs of conventional
therapies and diminishing access to health insurance may
also play a role. Financial barriers can prevent patients from
using conventional depression treatments. Regardless of
clinical efficacy, self-treatment St. John’s wort is a relatively
inexpensive alternative to conventional medical care.
Implications for Policy, Delivery, or Practice: The growing
use of complimentary or alternative therapies like St. John’s
wort should be viewed in the context of rising costs and
shrinking access. From a clinical perspective, self-treatment
with herbal preparations is a potentially risky alternative to
conventional treatment. Depression is a serious but treatable
chronic illness. From a policy perspective, ongoing studies of
the safety and efficacy of herbs like St. John’s wort are a
priority. But for patients to make a truly informed treatment
decision, access to conventional care should also be assured.
Primary Funding Source: No Funding
●The Effect of Alternative Staff Time Data Collection
Methods on Drug Treatment Service Cost Estimates
Gary Zarkin, Ph.D., Laura J Dunlap, MA, Alexander J Cowell,
Ph.D., Brendan Wedehase, BA, Ling Lew, BA, Daniel Kaskubar,
BA
Presented By: Gary Zarkin, Ph.D., Director, Behavioral Health
Research Division, Behavioral Health Research Division, RTI
International, 3040 Cornwallis Road, Research Triangle Park,
NC 27709; Tel: 919-541-5858; Fax: 919-485-5555; Email:
gaz@rti.org
Research Objective: Managed care and reductions in
government spending have placed great pressure on
providers, payers, and researchers to demonstrate the costeffectiveness and cost-benefits of drug treatment services. As
a first step in these economic evaluations, the costs of specific
treatment services must be estimated. Although much
previous work has estimated drug treatment costs, only a very
limited number of service cost estimates exist, and no study
has evaluated the effect of alternative data collection methods
on estimated service costs. Our analysis evaluates three
alternative methods for estimating service-level costs in
methadone treatment programs. These three methods differ
in how they capture staff time allocation across treatment
services.
Study Design: The three alternative data collection methods
are (1) a survey of the clinic director (key informant), (2)
surveys of the clinic staff (staff informants), and (3) staff
diaries filled out for one week. Our analysis assesses the
extent to which differences in the method used to collect the
staff time allocation across alternative treatment services
contribute to differences in service cost estimates. In
addition, as part of the service cost evaluation, we estimate
the costs of collecting staff time allocation data for each of the
three data collection methods.
Population Studied: Our analysis is performed with data
from 25 methadone clinics located across the country.
Principal Findings: Service-cost estimation provides
meaningful results and has “convergent validity”—increases
confidence in service cost results. Service costs are
approximately the same for all 3 methods.
Conclusions: Given the lower burden of key informant
method, our preliminary results suggest that this method may
be preferred for most uses. However, for programs where the
key informant is not well-informed about staffing (e.g., large
programs, higher proportion of part-time/weekend staff), the
time allocation survey may dominate.
Implications for Policy, Delivery, or Practice: Results from
our analysis will yield an improved service cost estimation
methodology that accurately reflects the provision of
treatment services in drug treatment programs while
minimizing the burden placed on the respondent.
Primary Funding Source: NIDA
●Sociodemographic Determinants of Psychotropic
Medication Use in a Medicaid-insured Youth Population
Julie Zito, Ph.D., Anthony Kouzis, Ph.D., Daniel J. Safer, M.D.,
James F. Gardner, Sc.M., James Korelitz, Ph.D., Donald
Mattison, M.D.
Presented By: Julie Zito, Ph.D., Assoc Prof Pharmacy and
Psychiatry, Pharmaceutical Health Services Research,
University of Maryland, Baltimore, 515 W. Lombard St. Rm 252,
Baltimore, MD 21201; Tel: 410-706-0524; Fax: 410-706-5394;
Email: jzito@rx.umaryland.edu
Research Objective: Recent research suggests that
geographic variation in the use of mental health services for
children is more critical than racial/ethnic differences (Sturm
et al., 2003). A study was undertaken addressing this
hypothesis in regard to psychotropic medication use among
Medicaid-insured youth in 4 U.S. regions.
Study Design: A cross-sectional analysis of computerized files
(MAX files from The Centers for Medicare and Medicaid
Services) comprised enrollment data and outpatient
prescription claims data. Prevalence of use was defined as the
probability of a youth having one or more dispensed
prescriptions for a psychotropic medication during their
enrollment time in the year 2000, with an adjustment made
for youth not enrolled for the full one-year period.
Population Studied: Medicaid-insured youth (N=5,030,185)
<18 years of age from 17 states were randomly selected from
the states in 4 regions: Northeast (N=451,289), South
(N=1,535,725), Midwest (N=2,570,554) and West (N=472,617).
Principal Findings: The prevalence of use of a psychotropic
medication averaged 8.4% and ranged across regions from a
low of 7.4% to a high of 10.1%. Compared to the West, the
probability of use was greater by the following percentages:
Northeast (60%), South (50%), and Midwest (30%) adjusted
for age, gender and race/ethnicity. Use of a psychotropic in 1014 year olds exceeded the other age groups (0-4, 5-9, and 15-17
year olds) by 3-4-fold. Males were 70% more likely to receive a
psychotropic than females, as has been noted previously.
White youth were approximately twice as likely (Odds
Ratio=1.9) and Hispanic and Other youth were significantly
less likely (Odds Ratio 0.6 in each group) than AfricanAmerican youth to have a psychotropic medication dispensed.
For specific drug classes, differences by race/ethnicity were
greater for antidepressants and lithium than for antipsychotics
and anxiolytics.
Conclusions: In a dataset representing nearly one-third of all
Medicaid-insured youth, regional variation in psychotropic
medication use contrasted with marked race/ethnicity group
differences. The hypothesis that region is relatively more
important than race/ethnicity was not supported with regard
to psychotropic medication use.
Implications for Policy, Delivery, or Practice: Programs
developed to improve clinical mental health service use
should address the cultural acceptability and outcomes of
psychotropic medication use among non-white youth.
Primary Funding Source: National Institute for Child Health
and Human Development