Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE

To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied.

METHODS

A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units.

RESULTS

After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units.

CONCLUSION

Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.

Personal and psychosocial risk factors for physical and mental health outcomes and course of depression among depressed patients

This article focuses on personal and psychosocial factors to identify those that predict change in functioning and well-being and clinical course of depression in depressed outpatients over time. Data from 604 depressed patients in The Medical Outcomes Study showed improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles. Better clinical course of depression was associated with patients who had high levels of social support, who had more active and less avoidant coping styles, who were physically active, and who had fewer comorbid chronic conditions. Findings provide some guidance as to what can be done to improve depressed patients' levels of physical and mental health and affect the clinical course of depression.

Quality of care for depressed elderly patients hospitalized in the specialty psychiatric units or general medical wards

BACKGROUND

Studies to assess quality of care have become increasingly important for research and policy purposes.

OBJECTIVE

To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards.

METHODS

We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes.

RESULTS

We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit.

CONCLUSIONS

Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.

Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the Medical Outcomes Study

OBJECTIVE

We compare mental health utilization in prepaid and fee-for-service plans and analyze selection biases.

DATA SOURCE

Primary data were collected every six months over a two-year interval for a panel of depressed patients participating in the Medical Outcomes Study, an observational study of adults in competing systems of care in three urban areas (Boston, Chicago, and Los Angeles).

STUDY DESIGN

Patients visiting a participating clinician at baseline were screened for depression, followed by a telephone interview, which included the depression section of the NIMH Diagnostic Interview Schedule. Patients with current or past lifetime depressive disorder and those with depressed mood and three other lifetime symptoms were eligible for this analysis. We analyze mental health utilization based on periodic patient self-report. ANALYTIC METHODS: We use two-part models because of the presence of both nonuse and skewness of use. Standard errors are corrected nonparametrically for correlations across observations due to clustered sampling within participating physicians and repeated observations on the same individual.

PRINCIPAL FINDINGS

The average number of mental health visits was 35-40 percent lower in the prepaid system, adjusted and unadjusted for observed differences in patient characteristics, including health status. Utilization differences were concentrated among patients of psychiatrists, with only minor differences among patients of general medical providers. Analyzing the effect of switches that patients make between payment systems over time, we found some evidence of adverse selection into fee-for-service plans based on baseline utilization, but not based on utilization at the end of the study. In particular, after adjusting for observed patient characteristics and health status, patients switching out of prepaid plans had higher baseline use than predicted, whereas patients switching out of fee-for-service had lower use than predicted. Switching itself appears to be related to an immediate decline in utilization and was not followed by an increase or "catch-up" effect.

CONCLUSIONS

The absence of the commonly found "catch-up" effect following switching and the significant decrease in utilization during the switching period suggests an interruption in care that does not occur for patients staying within a payment system. This finding emphasizes the need for integrating new patients quickly into a system, an issue that should not be neglected in the current policy discussion.

Personal and psychosocial risk factors for physical and mental health outcomes and course of depression among depressed patients

This article focuses on personal and psychosocial factors to identify those that predict change in functioning and well-being and clinical course of depression in depressed outpatients over time. Data from 604 depressed patients in The Medical Outcomes Study showed improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles. Better clinical course of depression was associated with patients who had high levels of social support, who had more active and less avoidant coping styles, who were physically active, and who had fewer comorbid chronic conditions. Findings provide some guidance as to what can be done to improve depressed patients' levels of physical and mental health and affect the clinical course of depression.

Prevalence of behavior problems in US children with asthma

OBJECTIVES

To present national population-based estimates of the prevalence of parent-reported emotional and/or behavioral problems in children with asthma and the relationship of medical comorbidity and asthma severity with behavior problems.

DESIGN

Cross-sectional study of the 1988 National Health Interview on Child Health.

MAIN OUTCOME MEASURES

Parent responses to a checklist of child health conditions were used to assign school-age children (5 to 17 years old) into one of four groups: children without reported chronic conditions; children with asthma alone; children with asthma and additional reported chronic conditions; and children with the same chronic conditions, but without asthma. Parental responses to the Behavior Problem Index (BPI) were used for construction of an overall BPI score, as well as subscale scores. Cross-tabulation and linear and logistic regression were used to determine the relation of the different condition categories to emotional and/or behavioral problems expressed by relative values of the BPI.

RESULTS

Children with asthma and comorbid conditions had a mean BPI score of 7.3, compared with 5.4 for children without chronic conditions, and all subscale scores, except those for antisocial conduct and immature behavior, were significantly elevated. Using logistic regression to control for confounding variables, children with severe asthma alone had nearly three times the odds (odds ratio, 2.96; 95% confidence interval, 1.22 to 7.17) and children with asthma plus comorbid conditions nearly twice the odds (odds ratio, 1.86; 95% confidence interval, 1.20 to 2.90) of children without chronic conditions to have severe behavior problems.

CONCLUSIONS

Severe asthma and asthma with medical comorbidity represent significant risk factors for emotional and/or behavioral problems. Clinicians caring for children with asthma and their families should be aware of the relationship between asthma and emotional and/or behavioral problems and anticipate that a substantial number of their patients may have mental health services needs.

Cost containment and mental health outcomes: experiences from US studies

BACKGROUND

Cost containment mechanisms, such as prepayment, are being considered or implemented in the US and elsewhere, but there have been few studies of the effects of such mechanisms on quality or outcomes of care for individuals with serious psychiatric disorders.

METHOD

Key results from US studies on cost containment and their implications are reviewed.

RESULTS

Cost savings in out-patient mental health care can be achieved through increasing the share of costs paid by the covered individual or through prepayment, but individuals with the greatest psychological distress or poor people may achieve worse outcomes under greater cost containment. Quality of care may be poorer under some forms of prepayment than under fee-for-service care, yet a national prospective payment mechanism for depressed elderly in-patients was not associated with a marked drop in quality or outcomes of care among those admitted.

CONCLUSIONS

Prepayment, relative to fee-for-service is not always associated with lower outcomes or quality of care for affective disorders. Under cost containment, quality and outcomes of care, especially for the sick poor, should be monitored to identify adverse consequences.

Severity of depression in prepaid and fee-for-service general medical and mental health specialty practices

This study compares severity of depression for patients of general medical clinicians, psychiatrists, and nonphysician therapists receiving prepaid or fee-for-service care. Cross-sectional severity comparisons were conducted among 715 outpatients with current major depression or dysthymia, by independent assessment. Severity was assessed by counts of current and lifetime depressive symptoms, prognostic and treatment response indicators, and global measures of psychological and physical sickness. Patients of psychiatrists were the most psychologically ill, patients of nonphysician therapists were intermediate, and general medical patients were least ill; but even in the general medical sector, depression severity was at least ill; but even in the general medical sector, depression severity was at least moderate. No differences in global physical sickness by specialty remained after demographic adjustment. General medical patients whose depression had been detected were only slightly sicker than undetected cases. Type of payment was not consistently related to either psychological or physical aspects of sickness, and payment did not interact with specialty. Mental health specialists, especially psychiatrists, encountered more severely depressed patients, but patients in all sectors were sick enough to warrant treatment. Even undetected patients in the general medical sector were relatively sick, raising questions about gatekeeper policies. There was no evidence of a greater severity gradient by specialty in prepaid care. Because payment was unrelated to severity, treatment implications are similar under prepaid and fee-for-service care. Implications for clinical practice, public policy, and outcomes research design are discussed.

How can care for depression become more cost-effective?

OBJECTIVE

To determine the cost and health effects of changes in the content and quality of care for depressed patients treated in prepaid general medical practices (internal and family medicine) and mental health specialty practices and shifts in the proportion of patients treated in general medicine.

METHODS

Cost-effectiveness analysis and simulations, which are empirically based on data from the Medical Outcomes Study.

OUTCOME MEASURES

Change in serious functional limitations, annual treatment costs per patient, and costs per reduction in one functional limitation.

RESULTS

More appropriate care for depression (increased counseling, use of appropriate antidepressant medications, or avoidance of regular minor tranquilizer use) improves functioning outcomes. Although this approach increases total costs of care, it also improves the value of care because each dollar spent on care now provides more benefits in terms of health improvements. In contrast with the effects of more appropriate care for depression, the trend away from mental health specialty care and toward general medical provider care under current treatment patterns reduces costs, worsens outcomes, and does not increase the value of health care spending in terms of health improvement per dollar.

CONCLUSION

Quality improvement measures that roughly follow practice guidelines for depression can improve outcomes and the value or cost-effectiveness of care, but at increased treatment costs; shifting patients away from mental health specialists decreases costs but worsens functioning outcomes. The best strategy for making care for depression more cost-effective is through quality improvement, not through changing specialty mix. Yet combining these strategies may achieve better outcomes, lower treatment costs, and better value of care compared with current practice patterns. To realize this potential, however, substantial quality improvement of care for depression is necessary in general medical practice.

Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses

BACKGROUND

Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known.

METHODS

We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care.

RESULTS

Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations.

CONCLUSION

Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses.

Care for depression in a changing environment

The U.S. health care system is quickly changing, but is it moving in the right direction? Focusing on care for clinical depression as a test case, this paper summarizes our previously published findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions. We then synthesize the policy implications of these findings for achieving value of care, lower costs, and good health outcomes.

Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients

OBJECTIVE

The authors examined the clinical significance of depressive symptoms below the threshold for depressive disorder in outpatient samples.

METHOD

The subjects were 775 adult patients with current depressive disorder, 1,420 patients with subthreshold depression, and 1,767 hypertensive patients with and without depression, all of whom were visiting the offices of mental health specialists and general medical care providers in three U.S. cities. Data on demographic characteristics, severity of depression, extent of psychiatric and medical comorbidity, family psychiatric history, and treatment history for the patients with depressive disorder and those with subthreshold depression were compared.

RESULTS

The percentage of patients with subthreshold depression who had a family history of depression (41%) was nearly as high as that of the patients with depressive disorder (59%). The two groups of patients had similar levels of medical and psychiatric comorbidity except for anxiety disorders, which were greater among the patients with depressive disorder. Among the hypertensive patients in the general medical sector, those with subthreshold depression were more similar to those with depressive disorder than to the nondepressed hypertensive patients. Treatment rates were considerably lower for patients with subthreshold depression than for patients with depressive disorder in the general medical sector, but they were similar in the mental health specialty sector.

CONCLUSIONS

In these outpatients, subthreshold depression appeared to be a variant of affective disorder and was treated as such in the mental health specialty sector but not in the general medical sector. The findings emphasize the importance of treatment outcome studies of patients with subthreshold depression.

Clinician specialty and treatment style for depressed outpatients with and without medical comorbidities

BACKGROUND

The advent of clinical practice guidelines for the management of depression increases the importance of understanding variation across clinician specialty groups in treatment styles for depression and the role of medical comorbidities.

METHODS

Data are reported by clinicians (N = 470) and patients (N = 2545). Multiple regression was used to compare the treatment styles (counseling and prescribing antidepressants) of family physicians with those of psychiatrists, medical subspecialists, internists, psychologists, and other therapists for depressed patients with different medical comorbidities.

RESULTS

Relative to other primary care specialists, family physicians had the strongest preferences for both counseling and prescribing antidepressants for depressed patients. Family physicians reported preferences for treating with antidepressants that were similar to those of psychiatrists. However, in actual practice, medication use was higher among the patients of psychiatrists than those of family physicians. Mental health care specialists reported the strongest counseling preferences and provided the most counseling in actual practice, compared with general medicine physicians. Internists and subspecialists had similar preferences for prescribing antidepressants, but, compared with internists, subspecialists had lower preferences for counseling. Clinician preferences for counseling were similar for depressed patients with or without medical comorbidities, but preferences for prescribing antidepressants were lowest for patients with depression and myocardial infarction, compared with other patient groups.

CONCLUSIONS

Measures of clinician treatment style for depression are good proxies for counseling but not for prescribing practices. Among general medical physicians, family physicians have the strongest reported preferences in treating depression but, especially in terms of medication therapy, do not always follow those preferences. Preferred treatments of patients with and without medical comorbidities were similar. Findings have implications for improving the quality of treatment of depressed patients.

Switches between prepaid and fee-for-service health systems among depressed outpatients: results from the Medical Outcomes Study

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the Medical Outcomes Study

This study was carried out to determine whether levels of physical activity of patients with various chronic diseases are associated with subsequent functioning and well-being. It was an observational 2-year longitudinal design. The setting was offices of medical and mental health practices within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three U.S. cities. Included in the study were 1758 adult patients with one or more of the following: diabetes, hypertension, congestive heart failure, recent myocardial infarction, depressive symptoms, or current depressive disorder. Outcome measures included physical, role, and functioning; energy/fatigue; pain intensity; sleep problems; depressed affect, anxiety, positive affect, and overall psychological distress/well-being; health distress; and current health perceptions. Cross-sectional (base-line), 2-year endpoint, and change score relationships were evaluated between baseline levels of physical activity and each outcome, controlling for chronic conditions, comorbidity, smoking, alcohol use, overweight, self-reported adherence, and other patient and study characteristics. Higher baseline levels of exercise were uniquely associated with better functioning and well-being at baseline and 2 years later for some measures. The magnitude of the differences varied by disease group, but tended to be between 0.17 and 0.39 of the baseline SD. Greater levels of exercise are associated with feeling and functioning better for patients with chronic conditions over a 2-year period, suggesting that this is a fruitful area for further study using controlled interventions.

Depression in general medical settings. Implications of three health policy studies for consultation-liaison psychiatry

Prepaid or prospective reimbursement has implications for the consultation-liaison (C-L) psychiatrist. The author reviews results from three health policy studies that indicated 1) degree of reliance on general medical providers for mental health care is not affected by generosity of fee-for-service (FFS) coverage, but is greater in some prepaid health care systems; 2) psychological sickness of depressed outpatients visiting general medical providers is similar across prepaid and FFS systems of care; 3) prepaid care is associated with lower rates of detection of depression and counseling in the general medical sector; 4) depression outcomes in the general medical sector are similar under prepaid or FFS care; 5) quality of care for depressed patients is moderate to low in the general medical sector; and 6) depressed elderly inpatients receive higher quality of psychological care in psychiatric units, but they receive higher quality of physical care in general medical wards. The discussion emphasizes the C-L psychiatrist's role in educating general medical providers, improving outcomes for the sickest patients, and improving psychosocial care in prepaid practices.

Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study

OBJECTIVE

The purpose of this study was to compare use of minor tranquilizers and antidepressant medications by depressed outpatients across different treatment settings.

METHOD

The study subjects were 634 patients with current depressive disorder or depressive symptoms who visited general medical clinicians, psychiatrists, psychologists, or other therapists. Data on use of medication in different types of clinical practices with different types of payment plans were gathered from structured interviews by study clinicians and from surveys of patients.

RESULTS

Of the depressed patients, 23% had recently used an antidepressant medication and 30% had used a minor tranquilizer. The level of use was similar for different types of depression. Patients of psychiatrists were the most likely to use medications. In the practices of physicians, but not nonphysicians, the more severely distressed patients were more likely to use antidepressant medications. Of the patients taking an antidepressant medication, 39% used an inappropriately low dose. Patients in prepaid health care plans were twice as likely as those in fee-for-service care to use minor tranquilizers.

CONCLUSIONS

Less than one-third of the depressed outpatients used antidepressant medications, and the probability of use was similar for major depression and other types of depression for which efficacy is less well established. Use of antidepressant medications among patients of nonphysicians was unrelated to the level of psychological sickness, suggesting the need for more cooperation among provider groups. Minor tranquilizers were used more often than antidepressants, particularly among patients in prepaid plans, despite controversy over their efficacy.

Quality of care for depressed elderly pre-post prospective payment system: differences in response across treatment settings

We evaluated the quality of care for depressed elderly patients (n = 2,746) hospitalized in general medical hospitals (n = 297) before or after implementation of Medicare's Prospective Payment System, focusing on whether the response to time period differed for hospitals that in the post-PPS period had no psychiatric unit, an exempt psychiatric unit, or a nonexempt unit, and by ward placement within hospitals with psychiatric units. Quality of care increased over time, and for most measures of quality of care the level of improvement did not differ significantly across different types of hospitals or by ward placement. The intensity of use of therapeutic services, such as rehabilitation, occupation, or recreation therapy, increased over time, particularly in nonexempt psychiatric units and hospitals without psychiatric units, such that these locations caught up some over time in the level of use of these services to the level for exempt psychiatric units. Several outcomes of care improved over time, and the degree of improvement in the rate of inpatient medical and psychiatric complications and other outcomes was significantly greater for psychiatric units that were exempt post-PPS than for nonexempt treatment locations.

Emotional and behavioral problems and severe academic delays among sheltered homeless children in Los Angeles County

OBJECTIVES

Few studies have estimated the extent of specific emotional, behavioral, and academic problems among sheltered homeless children. The objectives of this study were to describe such problems, identify those children with the problems, and evaluate the relationship between child problems and use of physical and mental health services.

METHODS

From February through May 1991, 169 school-age children and their parents living in 18 emergency homeless family shelters in Los Angeles County were interviewed. To evaluate the answers, interviewers used standardized measures of depression, behavioral problems, receptive vocabulary, and reading.

RESULTS

The vast majority (78%) of homeless children suffered from either depression, a behavioral problem, or severe academic delay. Among children having a problem, only one third of the parents were aware of any problem, and few of those children (15%) had ever received mental health care or special education.

CONCLUSIONS

Almost all school-age sheltered homeless children in Los Angeles County have symptoms of depression, a behavioral problem, or academic delay severe enough to merit a clinical evaluation, yet few receive specific care. Programs targeted at sheltered homeless school-age children are needed to close this gap.

Do depressed patients in different treatment settings have different levels of well-being and functioning?

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in health maintenance organizations, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being "burden" but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider.

Quality of antidepressant medications prescribed at discharge to depressed elderly patients in general medical hospitals before and after prospective payment system

This study describes the quality of antidepressant medication use at hospital discharge for depressed elderly inpatients and compares quality of care before and after implementation of Medicare's Prospective Payment System (PPS). The study reviewed data from medical records of 2746 depressed, elderly, hospitalized patients in acute-care general medical hospitals in five U.S. states (pre-PPS period 1981-82; post-PPS period 1985-86). The majority were discharged on antidepressant medication both pre-PPS and post-PPS. After PPS' implementation, sedating medications were used less often in all treatment settings. In general medical wards, a higher percentage post-PPS (24%) than pre-PPS (14%) were discharged 48 hours or less after first starting an antidepressant medication. In both time periods, one-third of patients receiving antidepressant medications were prescribed daily dosages at discharge below recommended, minimum, therapeutic levels, whether treated in general medical wards or psychiatric units. Otherwise, patients previously treated in psychiatric units received higher quality of medication management than those treated in general medical wards. Over time, patients discharged on antidepressant medication were less likely to use sedating medication, suggesting improved quality of care. In general medical wards, however, patients were discharged more rapidly after starting medication, possibly suggesting lower quality of care. A substantial percentage of patients received subtherapeutic dosages of medication or sedating medications, suggesting that improved management of discharge antidepressant medication in the elderly is needed in general medical hospitals.

Quality of care for hospitalized depressed elderly patients before and after implementation of the Medicare Prospective Payment System

OBJECTIVE

The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depressed elderly inpatients in acute-care general medical hospitals.

METHOD

The depressed elderly inpatients (N = 2,746) were hospitalized in 297 acute-care general medical hospitals. The authors used a retrospective before-and-after design, controlling for differences over time in sickness at admission. Quality of care and outcomes were assessed through clinical review of explicit and implicit information in the medical records; secondary data sources provided information on postdischarge outcomes.

RESULTS

After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-care admissions; 2) the initial assessment of psychological status by the treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient readmission declined; and 5) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall clinical status at discharge or the rate of mortality 1 year after admission.

CONCLUSIONS

After the implementation of the Medicare Prospective Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcomes. Despite these gains, after implementation the quality of care was moderate at best and over one-third of the patients had unacceptable clinical status at discharge.

Prevalence of comorbid alcohol disorder and consumption in medically ill and depressed patients

OBJECTIVE

To estimate the extent to which alcohol disorder co-occurs in patients with major medical and psychiatric conditions.

DESIGN

Observational study.

SETTING

Offices of general medical providers and mental health specialists in three US cities.

PATIENTS

Adult patients (N = 2296) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current depressive disorder or subthreshold depressive symptoms.

MAIN OUTCOME MEASURES

Current and lifetime alcohol disorder, alcohol consumption, current problem drinking, perceived need for help for alcohol or other drug problems, and unmet need.

METHODS

Comparisons of the prevalence of alcohol comorbidity in medically ill nondepressed patients of general medical providers and in depressed patients of both provider types.

RESULTS

Patients with chronic medical problems or depression had similar levels of lifetime alcohol disorder (14% to 19%) and current alcohol problems (18% to 29%), but depressed patients were more likely to report needing help for problems with alcohol or drugs. Current alcohol disorder was more prevalent among depressed patients in mental health specialty practices than in general medical practices. Many patients who perceived a need for care for alcohol and other drug problems reported that this need was unmet (37% to 84%).

CONCLUSIONS

Clinicians who treat patients with major medical and psychiatric conditions need to be prepared to identify and treat comorbid alcohol disorder.

Do depressed patients in different treatment settings have different levels of well-being and functioning?

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in health maintenance organizations, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being "burden" but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider.