Chronic Illness with Complexities: Mental Illness and Substance Use Among Veteran Clinic Users with Diabetes

Daily Functioning of Veterans With Type 2 Diabetes: Protocol for an Ambulatory Assessment Study

BACKGROUND

Diabetes impacts nearly 25% of veterans. Many veterans do not engage in recommended physical activity and other diabetes self-management behaviors. Type 2 diabetes is generally asymptomatic; as such, the long-term consequences of inadequate self-management and benefits of consistent self-management are not salient in the short term. Furthermore, self-management behaviors typically take place outside of medical visits; however, self-management-related factors are only assessed during medical visits, likely missing large amounts of variability. Thus, ambulatory assessment methods such as ecological momentary assessment (EMA), accelerometry, and continuous glucose monitoring are needed to understand the dynamics of daily self-management and identify potential intervention targets.

OBJECTIVE

The overarching goal of this study is to understand daily, time-varying factors (comorbid affective symptoms and social context) that influence physical activity, diabetes self-management, glycemic management, daily functioning, and quality of life in participants' natural environments.

METHODS

We are recruiting veterans with type 2 diabetes (target N=100). Participants are required to complete a battery of baseline assessments related to mental health, psychosocial factors, and self-management behaviors. Participants then receive 5 momentary EMA surveys and 1 daily EMA survey per day, in which veterans report comorbid affective symptoms (mood, stress, and pain), social support, social interactions, physical activity, and other self-management behaviors. Momentary surveys are delivered randomly during daily preprogrammed intervals over a 14-day sampling period. Accelerometry and continuous glucose monitoring are also used to assess physical activity and blood glucose, respectively. The first 6 participants also completed interviews assessing their experience in the study and barriers to participation. These test participants informed modifications to the protocol for the remaining participants.

RESULTS

The project received funding in April of 2023. Enrollment began in March of 2023 and is planned to be completed in April 2025. Among the 6 test participants, the overall EMA response rate was 87% (range 74%-95%). The response rate for the EMA survey including daily items (67%, range 21%-93%) was lower than the earlier shorter EMA surveys (89%, range 81%-96%). The mean rate of valid accelerometer wear of at least 20 hours per day was 93% (SD 11%), and continuous glucose monitoring data were available for 91% (SD 17%) of days on average. Participants reported few barriers to completing EMA surveys but noted the random timing of questions made it difficult to plan around, and the end-of-day survey was long. Two participants reported survey items reminded or motivated them to engage in diabetes self-management behaviors.

CONCLUSIONS

Assessment tools developed from this study can inform clinical decision-making by considering barriers to self-management that occur in daily life. Clinical applications include tailored, adaptive technology-supported interventions to improve self-management that provide the right type and amount of support at the right time by adapting to an individual's changing internal and contextual state.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53874.

Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness

OBJECTIVE

Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education.

METHODS

This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends.

RESULTS

Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%.

CONCLUSIONS

Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.

Generalized anxiety disorder in type 2 diabetes mellitus: prevalence and clinical characteristics

Objective:

This study investigated the prevalence of generalized anxiety disorder (GAD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

Methods:

This retrospective observational study was conducted with a random sample of patients from the entire population of National Health Insurance enrollees during 2000-2010 and used ICD-9-CM diagnostic codes to identify T2DM patients and GAD. The prevalence of GAD was compared between T2DM patients and the general population.

Results:

Between 2000 and 2010, the prevalence of GAD was significantly greater in the T2DM patients than the general population, while the increase of GAD was higher in the general population (from 0.25 to 0.63%) than among T2DM patients (from 0.81 to 1.03%). In T2DM patients, GAD was associated with female gender, a Charlson Comorbidity Index ≥ 1, diabetes mellitus duration > 9 years, and the following comorbidities: congestive heart failure, peripheral vascular disease, and depressive disorder. The prevalence of GAD among T2DM patients was negatively associated with rapid-acting insulin injection therapy and with the use of metformin and sulfonylureas.

Conclusion:

Since the prevalence of GAD was greater among T2DM patients than the general population, public health initiatives are needed to prevent and treat GAD in T2DM patients, specifically those with the above mentioned risk factors.

Psychosocial and Clinical Risk Factors Associated with Substance Use in Observational Cohort of Patients with Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) experience high rates of chronic pain, and have a high burden of mental health comorbidities shown to negatively influence health. There is limited research on substance use among individuals with SCD. Objective: The aim of this study is to measure the prevalence of substance use in patients with SCD and determine whether psychosocial or clinical risk factors are associated with substance use. Methods: This study was conducted as part of an observational study of patients with SCD at two academic medical centers. We asked participants (ages 15 and older) about the lifetime use of heroin, cocaine, amphetamines, and marijuana/cannabis. We measured stigma, depression, urban life stress, pain catastrophizing, and asked about a brief pain inventory. Results: Of 258 participants, 24.9% (n = 71) reported substance use. Marijuana was the most common substance used (22.5%; n = 65). The mean depressive score met criteria for positive screen amongst individuals who reported a history of substance use (mean 10.7(5.76)). Adjusting for age, sex, yearly family income, and education level, odds of substance use increased with higher levels of internalized stigma (aOR: 1.38; 95% CI: 1.07, 1.77; p = 0.012); higher urban life stress scores (aOR 1.06; 95% CI: 1.01, 1.12; p = 0.017) and higher pain catastrophizing scores (aOR: 1.03; 95% CI: 1.01, 1.06; p = 0.008). Conclusions: Among individuals with SCD who endorse substance use, there was markedly more stress and distress with higher rates of depression and poorer quality of life. Interventions focusing on improving distress tolerance and coping to not only pain, but also social stressors, might reduce substance use.

The Wellness Incentive and Navigation intervention improved health-related quality of life among Medicaid enrollees: A randomized pragmatic clinical trial

OBJECTIVE

To examine whether the Wellness Incentive and Navigation (WIN) intervention can improve health-related quality of life (HRQOL) among Medicaid enrollees with co-occurring physical and behavioral health conditions.

DATA SOURCES

Annual telephone survey data from 2013 to 2016, linked with claims data.

STUDY DESIGN

We recruited 1259 participants from the Texas STAR + PLUS managed care program and randomized them into an intervention group that received flexible wellness accounts and navigator services or a control group that received standard care. We conducted 4 waves of telephone surveys to collect data on HRQOL, patient activation, and other participant demographic and clinical characteristics.

DATA COLLECTION/EXTRACTION METHODS

The 3M Clinical Risk Grouping Software was used to extract variables from claims data and group participants based on disease severity.

PRINCIPAL FINDINGS

Our results showed that the WIN intervention was effective in increasing patient activation and HRQOL among Medicaid enrollees with co-occurring physical and behavioral health conditions. Furthermore, we found that this intervention effect on HRQOL was partially mediated by patient activation.

CONCLUSIONS

Providing navigator support with wellness account is effective in improving HRQOL among Medicaid enrollees. The pragmatic nature of the trial maximizes the chance of successfully implementing it in state Medicaid programs.

Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders

IMPORTANCE

Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote long-term medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management.

OBJECTIVE

To analyze how preexisting MH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017.

EXPOSURES

Patients were assigned to groups on the basis of a 2-year look-back period for MH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or no MH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabetes was diagnosed.

MAIN OUTCOMES AND MEASURES

Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores.

RESULTS

Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexisting MH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, -0.09; 95% CI, -0.13 to -0.04; P < .001) or both MH and SU disorders (decrease in DCSI score, -0.13; 95% CI, -0.16 to -0.09; P < .001), but not MH disorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, -0.41 [95% CI, -0.43 to -0.39] for 1-2 visits, -0.50 [95% CI, -0.52 to -0.48] for 3-4 visits, -0.39 [95% CI, -0.41 to -0.37] for 5-8 visits, and -0.15 [95% CI, -0.17 to -0.12] for ≥9 visits; P < .001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P < .001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P = .004; or both MH and SU disorders, 0.008 [95% CI, 0.006-0.011], P < .001), compared with patients without MH or SU disorders.

CONCLUSIONS AND RELEVANCE

Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.

Variations in VA and Medicare Use Among Veterans With Diabetes: Impacts on Ambulatory Care Sensitive Conditions Hospitalizations for 2008, 2009, and 2010

INTRODUCTION

VA and Medicare use among older Veterans has been considered fragmented care, however, it may represent access to needed care.

METHODS

The population studied were Veterans with diabetes, age 66 years and older, dually enrolled in VA and Medicare.

DATA SOURCE/STUDY SETTING

We conducted a dynamic retrospective cohort study with 2008, 2009, and 2010 as the outcome years (Ambulatory Care Sensitive Conditions Hospitalization (ACSC-H) or not). We analyzed administrative data to identify comorbidities; ambulatory care utilization to identify variations in use before hospitalization. We linked 2007 primary care (PC) survey data to assess if organizational factors were associated with ACSC-H.

MEASURES AND ANALYSIS

We identified ACSC-Hs using a validated definition. We categorized VA/Medicare use as: single system; dual system: supplemental specialty care use; or primary care use. Using hierarchical logistic regression models, we tested for associations between VA/Medicare use, organizational characteristics, and ACSC-H controlling for patient-level, organizational-level, and area-level characteristics.

RESULTS

Our analytic population was comprised of 210,726 Medicare-eligible Veterans; more than one quarter had an ACSC-H. We found that single system users had higher odds of ACSC-H compared with dual system specialty supplemental care use (odds ratio, 1.14; 95% confidence interval, 1.09-1.20), and no significant difference between dual-system users. Veterans obtaining care at sites where PC leaders reported greater autonomy (eg, authority over personnel issues) had lower odds of ACSC-H (odds ratio, 0.74; 95% confidence interval, 0.59-0.92).

DISCUSSION

Our findings suggest that earlier assumptions about VA/Medicare use should be weighed against the possibility that neither VA nor Medicare may address complex Veterans' health needs. Greater PC leader autonomy may allow for tailoring of care to match local clinical contexts.

The association between the number of chronic health conditions and advance care planning varies by race/ethnicity

Objectives: Although a national consensus exists on the need to increase the rates of advance care planning (ACP) for all adults, racial/ethnic differences in ACP have been consistently observed. This study investigated the intersection of racial/ethnic differences and the number of chronic health conditions on ACP among middle-aged and older adults in the United States.Method: Responses from 8,926 adults from the 2014 wave of the Health and Retirement Study were entered into multilevel hierarchical logistic regression analyses with generalized linear mixed models to predict ACP focused on assigning a durable power of attorney for healthcare (DPOAHC) and having a written living will after adjusting for covariates.Results: We found a significant positive relationship between the number of chronic health conditions and ACP. Non-Hispanic Blacks/African Americans and Hispanics were less likely to engage in ACP than non-Hispanic Whites/Caucasians. Racial/ethnic disparities were even starker for completing a living will. The number of chronic health conditions had a greater effect for Hispanics than non-Hispanic Whites/Caucasians on ACP through assigning a DPOAHC and having a living will. The initial disparity in ACP among Hispanics with no chronic health conditions decreased as the number of chronic health conditions increased.Conclusion: Our findings suggest that more chronic health conditions increase the likelihood that Hispanics will complete ACP documents. These ACP differences should be highlighted to researchers, policymakers, and healthcare professionals to reduce stark racial/ethnic disparities in ACP. A comprehensive and culturally caring decision-making approach should be considered when individuals and families engage in ACP.

Major depressive disorder in patients with type 2 diabetes mellitus: Prevalence and clinical characteristics

BACKGROUND

This study investigated the prevalence of major depressive disorder (MDD) among Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS

We enrolled patients with at least one service claim for ambulatory or inpatient care with a principal diagnosis of MDD and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of T2DM, as listed in Taiwan's National Health Insurance database.

RESULTS

We enrolled 715,756 people from the general population (GP), 61,589 patients with T2DM but without MDD, and 778 patients with both T2DM and MDD. The prevalence of MDD increased from 0.70% to 1.25% in the patients with T2DM, whereas it increased from 0.25% to 0.67% in the GP from 2000 to 2010. The higher prevalence of MDD was associated with the female sex, residing in the southern regions of Taiwan, and having comorbidities of cerebrovascular disease and anxiety disorder as well as higher comorbidity severity (Charlson comorbidity index, 1-2 and > 2).

LIMITATIONS

One limitation is the use of secondary data on diagnoses of MDD and T2DM. Another limitation is that we could not access some crucial related variables.

CONCLUSIONS

The prevalence of MDD was higher in the patients with T2DM than in the GP. In this study, the prevalence of MDD in the patients with T2DM was lower than that reported in Western countries.

Medication-assisted treatment for substance use disorders within a national community health center research network

BACKGROUND

The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations.

METHODS

Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013).

CONCLUSIONS

These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.

Health Care Utilization and Expenditures of Patients with Diabetes Comorbid with Depression Disorder: A National Population-Based Cohort Study

OBJECTIVE

The study investigated to compare health care utilization and expenditures between diabetic patients with and without depression in Taiwan.

METHODS

Health care utilization and expenditure among diabetic patients with and without depression disorder during 2000 and 2004 were examined using Taiwan's population-based National Health Insurance claims database. Health care utilization included outpatient visits and the use of inpatient services, and health expenditures were outpatient, inpatient, and total medical expenditures. Moreover, general estimation equation models were used for analyzing the factors associated with outpatient visits and expenditures. Multiple logistic regression analysis was applied for identifying the factors associated with hospitalization.

RESULTS

The average annual outpatient visits and annual total medical expenditures in the study period were 44.23-52.20; NT$87,496-133,077 and 30.75-32.92; NT$64,411-80,955 for diabetic patients with and without depression. After adjustment for covariates, our results revealed that gender and complication were associated with out-patient visits. Moreover, the time factor was associated with the total medical expenditure, and residential urbanization and complication factors were associated with hospitalization.

CONCLUSION

Health care utilization and expenditures for diabetic patients with depression were significantly higher than those without depression. Sex, complications, time, and urbanization are the factors associated with health care utilization and expenditures.

A 60-Week Prospective RCT of a Self-Management Intervention for Individuals With Serious Mental Illness and Diabetes Mellitus

OBJECTIVES

A 60-week randomized controlled trial assessed the effects of targeted training in illness management (TTIM) versus treatment as usual among 200 individuals with serious mental illness and diabetes mellitus.

METHODS

The study used the Clinical Global Impression (CGI), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Brief Psychiatric Rating Scale (BPRS) to assess psychiatric symptoms; the Global Assessment of Functioning (GAF) and the Sheehan Disability Scale (SDS) to assess functioning; the 36-Item Short-Form Health Survey (SF-36) to assess general health, and serum glycosylated hemoglobin (HbA1c) to assess diabetes control.

RESULTS

Participants' mean±SD age was 52.7±9.5 years, and 54% were African American. They were diagnosed as having depression (48%), schizophrenia (25%), and bipolar disorder (28%). At baseline, depression severity was substantial but psychosis severity was modest. At 60 weeks, there was greater improvement among TTIM participants versus treatment-as-usual recipients on the CGI (p<.001), the MADRS (p=.016), and the GAF (p=.003). Diabetes knowledge was significantly improved among TTIM participants but not in the treatment-as-usual group. In post hoc analyses among participants whose HbA1c levels at baseline met recommendations set by the American Diabetes Association for persons with high comorbidity (53%), TTIM participants had minimal change in HbA1c over the 60-week follow-up, whereas HbA1c levels worsened in the treatment-as-usual group.

CONCLUSIONS

TTIM was associated with improved psychiatric symptoms, functioning, and diabetes knowledge compared with treatment as usual. Among participants with better diabetes control at baseline, TTIM participants had better diabetes control at 60 weeks compared with recipients of treatment as usual.

Diabetes Knowledge Among Adults with Serious Mental Illness and Comorbid Diabetes Mellitus

This study examined the association between psychiatric symptoms and diabetes knowledge (DK) among 90 adults with serious mental illness (SMI) and type 2 diabetes. The relationship between DK and glucose control (i.e., A1C) was also examined. In a hierarchical linear regression, greater negative symptom severity and lower cognitive functioning both predicted lower DK, though cognitive functioning superseded negative symptom severity when analyzed simultaneously. A Pearson correlation showed no significant relationship between DK and A1C. Although symptom severity and cognitive functioning are both related to DK among this population, cognitive functioning maybe particularly important.

Prevalence of anxiety disorder in patients with type 2 diabetes: a nationwide population-based study in Taiwan 2000-2010

This study investigates the prevalence of anxiety disorder (AD) in Taiwanese patients with type 2 diabetes (T2D). Study participants were identified based on at least one service claim for ambulatory or inpatient care with a principal diagnosis of AD and at least 2 service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of T2D, as listed in the National Health Insurance database of Taiwan. The prevalence of AD decreased from 13.75 to 11.00 % in patients with T2D, whereas it increased from 4.17 to 6.09 % in the general population during the 2000-2010 period. A high prevalence of AD in patients with T2D was associated with age >30 years, the female sex, living in the northern region, comorbidities of congestive heart failure, peripheral vascular disease, cerebrovascular disease, and depression disorder, and a Charlson participant comorbidity index of ≥1. A low prevalence of AD in patients with T2D was associated with residency in urban areas, the comorbidity of hemiplegia or paraplegia, the usage of metformin and sulfonylureas, and rapid-acting insulin injection therapy. The prevalence of AD was higher in patients with T2D than in the general population. Therefore, more public health emphasis is required for preventing and treating AD in patients with T2D, specifically those with the mentioned risk factors.

Chronic Illness with Complexity

The present study examines how different chronic illnesses and mental illness comorbidity (chronic illness with complexity [CIC]) associate with components of advance care planning (ACP). We also explore the role self-perceived burden plays in the relationship between illness and ACP. Data were gathered from a cross-sectional survey of 305 elderly participants from the New Jersey End-of-Life study. Participants with diabetes and those with cardiovascular disease (CVD) are less likely, while participants with CIC are more likely, to plan for the end-of-life. Participants with diabetes are less likely to make formal plans, whereas those with CVD are less likely to hold informal discussions. CIC is associated with increased odds of having an advance directive, but no other form of ACP. Self-perceived burden did not appear to be the gateway by which illness groups differentially engaged in ACP. Future research should investigate what aspects of illnesses drive ACP.

Healthcare Utilization and Expenditures for Persons with Diabetes Comorbid with Mental Illnesses

The aim of this study was to investigate healthcare utilization and expenditure for patients with diabetes comorbid with and without mental illnesses in Taiwan. People with diabetes comorbid with and without mental illnesses in 2000 were identified and followed up to 2004 to explore the healthcare utilization and expenditure. Healthcare utilization included outpatient visits and use of hospital inpatient services, and expenditure included outpatient, inpatient and total medical expenditure. General estimation equation models were used to explore the factors associated with outpatient visits and expenditure. To identify the factors associated with hospitalization, multiple logistic regressions were applied. The average number of annual outpatient visits of the patients with mental illnesses ranged from 37.01 to 41.91, and 28.83 to 31.79 times for the patients without mental illnesses from 2000 to 2004. The average annual total expenditure for patients with mental illnesses during this period ranged from NT$77,123-NT$90,790, and NT$60,793- NT$84,984 for those without mental illnesses. After controlling for covariates, the results indicated that gender, age, mental illness and time factor were associated with outpatient visits. Gender, age, and time factor were associated with total expenditure. Age and mental illness were associated with hospitalization in logistic regression. The healthcare utilization and expenditure for patients with mental illnesses was significantly higher than for patients without mental illnesses. The factors associated with healthcare utilization and expenditure included gender, age, mental illness and time trends.

Self-Efficacy and Hemoglobin A1C Among Adults With Serious Mental Illness and Type 2 Diabetes: The Roles of Cognitive Functioning and Psychiatric Symptom Severity

BACKGROUND

Self-efficacy is a core element of diabetes self-care and a primary target of diabetes interventions. Adults with serious mental illness (SMI) are twice as likely as adults among the general population to have Type 2 diabetes. This population faces substantial barriers (i.e., cognitive impairment, psychiatric symptoms) to optimal diabetes self-care, but the relationship of these barriers to both self-efficacy and glycemic control (hemoglobin A1C [A1C]) is not clearly understood.

METHODS

Data collected from adult participants with SMI (i.e., schizophrenia, schizoaffective disorder, bipolar disorder) and Type 2 diabetes (n = 92) were used to examine the moderating effects of cognitive functioning and psychiatric symptoms (i.e., positive and negative symptoms) on the association between self-efficacy and A1C.

RESULTS

The relationship between self-efficacy and A1C was moderated by cognitive functioning (B = -4.03, standard error = 1.54, p = .011). Greater self-efficacy was associated with better glycemic control when cognitive functioning was high, but worse control when functioning was low. The relationship between self-efficacy and A1C was moderated by negative symptom severity (B = 6.88, standard error = 3.34, p = .043). Higher self-efficacy was associated with poorer glycemic control only when negative symptom severity was high. Positive symptoms did not interact with self-efficacy to predict A1C.

CONCLUSIONS

These results suggest that adults with SMI and low cognitive function or high negative symptom severity may misperceive their ability to manage their diabetes. They may benefit from efforts, including care management and monitoring, cognitive remediation, and skill training, to identify and correct inaccurate diabetes self-efficacy.

Mental health service use for adult patients with co-occurring depression and physical chronic health care needs, 2007-2010

BACKGROUND

Individuals with mental illness experience poor health and may die prematurely from chronic illness. Understanding whether the presence of co-occurring chronic physical health conditions complicates mental health treatment is important, particularly among patients seeking treatment in primary care settings.

OBJECTIVES

Examine (1) whether the presence of chronic physical conditions is associated with mental health service use for individuals with depression who visit a primary care physician, and (2) whether race modifies this relationship.

RESEARCH DESIGN

Secondary analysis of the National Ambulatory Medical Care Survey, a survey of patient-visits collected annually from a random sample of 3000 physicians in office-based settings.

SUBJECTS

Office visits from 2007 to 2010 were pooled for adults aged 35-85 with a depression diagnosis at the time of visit (N=3659 visits).

MEASURES

Mental health services were measured using a dichotomous variable indicating whether mental health services were provided during the office visit or a referral made for: (1) counseling, including psychotherapy and other mental health counseling and/or (2) prescribing of psychotropic medications.

RESULTS

Most patient office visits (70%) where a depression diagnosis was recorded also had co-occurring chronic physical conditions recorded. The presence of at least 1 physical chronic condition was associated with a 6% decrease in the probability of receiving any mental health services (P<0.05). There were no differences in service use by race/ethnicity after controlling for other factors.

CONCLUSIONS

Additional research is needed on medical care delivery among patients with co-occurring health conditions, particularly as the health care system moves toward an integrated care model.

Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study

OBJECTIVE

The aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan.

METHODS

Health care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000-2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization.

RESULTS

In the study period, the average number of annual outpatient visits was 43.11-50.37 and 29.82-31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875-92,781 and NT$63,764-81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure.

CONCLUSIONS

Health care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.

Factors associated with co-occurring medical conditions among adults with serious mental disorders

BACKGROUND

This study examined the prevalence and treatment of 17 co-occurring physical health conditions among adults with serious mental health disorders, and factors associated with prevalence of the 5 most common medical co-morbidities.

METHODS

Data were collected from 457 adults attending publicly funded mental health programs who participated in community health screenings held in 4 U.S. states. Face-to-face interviews included standardized items from the National Health Interview Survey and the National Health and Nutrition Examination Survey. Ordinary least squares regression analysis examined associations between prevalence of the 5 most common co-morbid conditions and respondents' demographic, clinical, attitudinal, and health insurance statuses.

RESULTS

Compared to the U.S. population, prevalence was significantly higher for 14 out of 17 medical conditions assessed. The 5 most common were hyperlipidemia (45%), hypertension (44%), asthma (28%), arthritis (22%), and diabetes (21%). Controlling for age, study site, and Medicaid status, racial/ethnic minorities were almost twice as likely as Caucasians to be diagnosed with hypertension and diabetes; women were almost twice as likely as men to be diagnosed with diabetes; and people with schizophrenia were around half as likely as those with other disorders to be diagnosed with hypertension and arthritis. Age was positively related to all conditions except asthma. Treatment prevalence was below 70% for approximately half of ongoing conditions.

CONCLUSIONS

These results suggest a high level of medical vulnerability and need for coordination of health and mental health services in this population. Associations with age, minority status, and gender point to the need for targeted health care strategies.

Comorbidity and functional correlates of anxiety and physical conditions in Canadian Veterans

Introduction: Little is known about the relationship between anxiety disorders and physical conditions in Canadian Veterans. The purpose of this investigation was to examine the comorbidity of anxiety and physical conditions and their relation to physical and mental health–related quality of life and activity limitations in a nationally representative sample of Canadian Veterans. Methods: Participants were selected from the cross-sectional 2010 Survey on Transition to Civilian Life ( N = 3,154, response rate = 71.0%). The sample consisted of former Canadian Armed Forces Regular Force personnel who were released from 1998 to 2007. Multivariate logistic and linear regression models evaluated associations between several commonly occurring chronic physical conditions and any anxiety disorder and correlates (i.e., quality of life and activity limitations) of comorbidity. Results: Any anxiety disorder was associated with significantly elevated rates of cardiovascular, gastrointestinal, respiratory, and musculoskeletal conditions; diabetes; and chronic pain after controlling for sociodemographics, military characteristics, any mood disorder, and heavy drinking. However, when additionally controlling for number of physical conditions, any anxiety disorder remained significantly associated with gastrointestinal conditions (adjusted odds ratio [AOR] = 1.63, 99% confidence interval [CI] = 1.07–2.50) and chronic pain (AOR = 1.79, 99% CI = 1.15–2.78). Co-occurring anxiety disorders and musculoskeletal conditions were associated with poorer physical health–related quality of life and activity limitations than musculoskeletal conditions alone. Conclusion: Anxiety disorders and physical health problems co-occur at high rates among Canadian Veterans, and this comorbidity is linked to poorer physical health–related quality of life and activity limitations. These findings have implications for supporting at-risk personnel with the transition to civilian life and for informing health promotion and prevention efforts.

Depressive disorders among cohorts of women veterans with diabetes, heart disease, and hypertension

OBJECTIVES

To compare the rates of major and minor depression in cohorts of women veterans with diabetes or heart disease or hypertension and examine variations in these rates by demographic, socioeconomic, and health status among these women.

METHODS

This was a retrospective cross-sectional analysis of fiscal year 2002 and 2003 data on 13,430 women veterans with diabetes or heart disease or hypertension who were diagnosed with depression and used Veteran Health Administration (VHA) clinics. International Classification of Diseases, 9th ed. Clinical Modification codes from merged VHA and Medicare claims files were used to identify diabetes, heart disease, hypertension, and depression. Chi-square tests and multinomial logistic regressions were used to characterize women veterans with major and minor depression.

RESULTS

Of all the women veterans diagnosed with diabetes or heart disease or hypertension and using the VHA clinics, 27% were diagnosed with depression. Of these 13,430 women with any depression, 60% were diagnosed with minor depression and 40% had major depressive disorders (MDD). Compared to major depression, minor depression was significantly more likely among women veterans who were older, without any other psychiatric condition and substance use disorders.

CONCLUSIONS

Minor depression is highly prevalent among women veterans with complex chronic illness, such as diabetes or heart disease or hypertension (i.e., women at risk or with cardiovascular conditions), suggesting a need to closely monitor these women to reduce the risk of major depression. Some subgroups of women were more likely to have minor depression than major depression; studies that exclusively focus on major depression will selectively miss these subgroups of women veterans.

Prevalence and incidence of diagnosed depression disorders in patients with diabetes: a national population-based cohort study

OBJECTIVE

This study aimed to investigate the prevalence and incidence of diagnosed depression disorders among patients with diabetes in Taiwan.

METHODS

Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of depression disorder, and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004, as found in the National Health Insurance database.

RESULTS

The 1-year prevalence of diagnosed depression disorders in the general population was 11.22 per 1000 in 2000, while the 5-year cumulative diagnosed prevalence increased to 40.76 per 1000 in 2004. The 1-year prevalence rate of diagnosed depression disorders among patients with diabetes was 33.95 per 1000 in 2000, and the 5-year cumulative prevalence increased to 92.17 per 1000 in 2004. Patients with diabetes had a higher 5-year cumulative prevalence and annual incidence than the general population throughout the observation period. A higher diagnosed prevalence was associated with a monthly income <US*$640 using multiple logistic regression analysis. Cox regression analysis revealed that a lower incidence was associated with male gender.

CONCLUSIONS

The prevalence and annual incidence density of diagnosed depression disorders in patients with diabetes were significantly higher than those in the general population. The prevalence of diagnosed depression disorder among patients with diabetes in Taiwan was lower than the rate in Western countries.

Impact of Abstinence Self-Efficacy and Treatment Services on Physical Health-Related Behaviors and Problems among Dually Diagnosed Patients

OBJECTIVE: Physical health problems are pervasive among patients with co-occurring substance use and mental disorders. Yet, drug treatment programs often ignore tobacco use and its association with health. Abstinence self-efficacy has been associated with improved outcomes for co-occurring disorders, which in turn may also impact physical health. This study had the goal of assessing whether abstinence self-efficacy for drugs and alcohol, and provision and use of services would influence tobacco use and other health-related outcomes among 351 individuals with co-occurring disorders in residential drug treatment. METHODS: Structural models tested the impact of baseline abstinence self-efficacy and treatment service characteristics on 6-month outcomes of health problems, functional limitations, health perceptions, and cigarette and heavy alcohol use. Demographics and baseline values for outcome variables were included as covariates. RESULTS: Correlations within time for poor health, cigarette use, and heavy alcohol use were substantial. A longer time in drug treatment was associated with less cigarette and heavy alcohol use at a 6-month follow-up. Baseline health problems were associated with more cigarette use and functional limitations at 6-months. Abstinence self-efficacy did not predict less cigarette use, but predicted less heavy alcohol use and fewer functional limitations. Availability of specialized dual-diagnosis groups and more on-site psychological services were not directly associated with outcomes, but had an impact through indirect effects on more psychological service utilization which predicted better subjective health. CONCLUSIONS: Improving overall treatment retention and services utilization among patients with co-occurring disorders may generalize to improved health perceptions, but specific health promotion and smoking-cessation interventions are warranted to improve health outcomes.

Decomposing gender differences in low-density lipoprotein cholesterol among veterans with or at risk for cardiovascular illness

OBJECTIVES

To measure the extent to which gender differences in poor lipid control among individuals at risk for cardiovascular diseases could be explained by patient-level characteristics.

STUDY DESIGN

Cross-sectional analyses of merged Veteran Health Administration (VHA) and Medicare claims data for the fiscal years (FY) 2002 and 2003 consisting of veterans using VHA facilities and were diagnosed with diabetes or heart disease or hypertension during FY 2002 and had recorded LDL cholesterol values in FY2003 (N = 527,568). There were 10,582 women and 516,986 men veterans. Poor lipid control was defined as LDL cholesterol values ≥130 mg/dL. Multivariate techniques consisted of logistic regressions. Based on the parameter estimates and distribution of individual characteristics, we used a decomposition technique to analyze factors that contributed to the gender difference in poor lipid control.

PRINCIPAL FINDINGS

A significantly higher percent of women (27.4%) than men (17.1%) had LDL cholesterol values ≥130 mg/dL. Of the 10.3 percentage point difference in lipid control, 3.4 percentage points were explained by variables included in the model. The gender difference in poor lipid control was mostly explained by age, physical illnesses, use of lipid lowering medications and depression.

CONCLUSIONS

Only one-third of the gender difference in poor lipid control could be explained by differences in individual characteristics, some of which are modifiable or could be used to identify groups at risk with poor lipid control. Our findings suggest that gender differences in lipid control could be partially reduced by increasing the prescription of lipid lowering drugs and treating depression among women. Interventions that improve lipid control in the non-elderly will also benefit women. However the largest part of the difference in lipid control between women and men remains unexplained and further research is needed to identify additional modifiable and unmodifiable factors.

Chronic disease and recent addiction treatment utilization among alcohol and drug dependent adults

BACKGROUND

Chronic medical diseases require regular and longitudinal care and self-management for effective treatment. When chronic diseases include substance use disorders, care and treatment of both the medical and addiction disorders may affect access to care and the ability to focus on both conditions. The objective of this paper is to evaluate the association between the presence of chronic medical disease and recent addiction treatment utilization among adults with substance dependence.

METHODS

Cross-sectional secondary data analysis of self-reported baseline data from alcohol and/or drug-dependent adults enrolled in a randomized clinical trial of a disease management program for substance dependence in primary care. The main independent variable was chronic medical disease status, categorized using the Katz Comorbidity Score as none, single condition of lower severity, or higher severity (multiple conditions or single higher severity condition), based on comorbidity scores determined from self-report. Asthma was also examined in secondary analyses. The primary outcome was any self-reported addiction treatment utilization (excluding detoxification) in the 3 months prior to study entry, including receipt of any addiction-focused counseling or addiction medication from any healthcare provider. Logistic regression models were adjusted for sociodemographics, type of substance dependence, recruitment site, current smoking, and recent anxiety severity.

RESULTS

Of 563 subjects, 184 (33%) reported any chronic disease (20% low severity; 13% higher severity) and 111 (20%) reported asthma; 157 (28%) reported any addiction treatment utilization in the past 3 months. In multivariate regression analyses, no significant effect was detected for chronic disease on addiction treatment utilization (adjusted odds ratio [AOR] 0.88 lower severity vs. none, 95% confidence interval (CI): 0.60, 1.28; AOR 1.29 higher severity vs. none, 95% CI: 0.89, 1.88) nor for asthma.

CONCLUSIONS

In this cohort of alcohol and drug dependent persons, there was no significant effect of chronic medical disease on recent addiction treatment utilization. Chronic disease may not hinder or facilitate connection to addiction treatment.

Prevalence and incidence of mental illness in diabetes: a national population-based cohort study

BACKGROUND

This study aimed to investigate the prevalence and incidence of mental illness among diabetic patients in Taiwan.

METHODS

Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of mental illness, and at least two claims for ambulatory care or one claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004.

RESULTS

The one-year prevalence of mental illness among diabetic patients was 20.6% in 2000, and the cumulative prevalence increased to 42.2% in 2004. Diabetic patients had a higher cumulative prevalence and annual incidence than the general population throughout the observation period. A higher prevalence was associated with age ≥45 and low income, and a lower prevalence with male gender and residing in rural areas. Cox regression analysis revealed that a higher incidence was associated with female gender, age ≥45, and low income.

CONCLUSIONS

The prevalence and annual incidence density of mental illness in diabetic patients were significantly higher than in the general population. Females had higher prevalence and incidence density of mental illness among diabetic patients. Mental illness in diabetic patients was more prevalent in elderly females of low income, and less in rural areas.

Impact of psychiatric comorbidity on mortality in veterans with type 2 diabetes

BACKGROUND

particular psychiatric disorders, such as depression, have a significant and negative effect on diabetes outcomes. However, we know very little about the impact of other psychiatric disorders, and of the effect of multiple psychiatric comorbidities, on the clinical course of diabetes. As such, the present study examined the impact of a wide range of psychiatric comorbidities on all-cause mortality in individuals with type 2 diabetes.

METHODS

retrospective follow-up was conducted of 15,065 veterans with type 2 diabetes enrolled in hospital care between 1997 and 2006. Clinical diagnoses from patient records were used to construct four psychiatric disorder scales: internalizing (i.e., depression and anxiety); externalizing (i.e., alcohol and drug abuse); psychotic; and bipolar. Longitudinal relationships were examined between these scales and mortality using Cox regression.

RESULTS

only externalizing disorders were significantly associated with mortality: hazard ratio = 1.22 (95% confidence interval = 1.02-1.47). In other words, each additional diagnosed externalizing disorder increased an individual's chance of dying over the follow-up period by 22%. This association remained significant when demographics and medical comorbidities were statistically controlled, but was rendered nonsignificant when medication adherence was introduced to the regression model.

CONCLUSIONS

the results provide evidence that among individuals with diabetes, alcohol and drug abuse/dependence have a significant impact on mortality. This increased risk of mortality may have been due to the association between psychiatric disorders and adherence to antidiabetes medications observed in the present study. Individuals with co-occurring diabetes and alcohol or drug abuse should be targeted for intensive interventions given their acute increased risk of mortality.

Prevalence and incidence of anxiety disorders in diabetic patients: a national population-based cohort study

OBJECTIVE

This study aimed to investigate the prevalence and incidence of anxiety disorders among diabetic patients in Taiwan.

METHODS

Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of anxiety disorders and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004 in the National Health Insurance database.

RESULTS

The 1-year prevalence rate of anxiety disorders among diabetic patients was 128.76 per 1000 in 2000, and the cumulative prevalence increased to 289.89 per 1000 in 2004. Diabetic patients had a higher cumulative prevalence and annual incidence than the general population throughout the observation period. A higher prevalence was associated with age (≥65, 55-64), female sex and low income by multiple logistic regression analysis. Cox regression analysis revealed that a higher incidence was associated with female sex and low income.

CONCLUSIONS

The prevalence and annual incidence density of anxiety disorders in diabetic patients were significantly higher than in patients with mental illness only in the general population. Female diabetic patients had a higher prevalence and incidence density of anxiety disorders. Anxiety disorders in diabetic patients were more prevalent in elderly women and in those with low income.

Excess mortality associated with mental illness and substance use disorders among veteran clinic users with spinal cord injury

PURPOSE

Among veterans with traumatic spinal cord injury (SCI) or disease aetiologies, examine the association between diagnosed mental illness (MI) and substance use disorders (SUD) on mortality after controlling for demographic and socioeconomic factors, SCI severity, injury duration and chronic physical illnesses.

METHOD

Longitudinal analysis of Veteran Health Administration(VHA) administrative data and Medicare claims for FY 1999-2004 matched with Spinal Cord Dysfunction-Registry (SCD-R) of VHA clinic users (N = 8334) with SCI. SCI was identified through SCD-R; individual MIs (anxiety, bipolar, depressive disorders, psychoses, post-traumatic disorder and schizophrenia) and SUDs (tobacco, alcohol and/or drug) were identified through ICD-9-CM codes. Cox-proportional hazards regressions were used to examine association between MI and SUD and time to death in years.

RESULTS

Among veterans with SCI, 17% died by the end of FY 2004. Veterans with psychosis (35%), depression (22%) and alcohol and/or drug use (20%) had significantly higher rates of mortality compared to those without these diagnoses. After adjusting for other independent variables in the study, hazards ratios for psychosis was 1.47 (95%CI = 1.24, 1.75), for alcohol and/or drug use was 1.30 (95% CI = 1.11, 1.53).

CONCLUSIONS

Some types of MI and SUD were associated with excess mortality among veterans with SCI. Care for MI and SUD needs to be routinely integrated into SCI management. Future research is needed to determine whether depression and SUD treatment provides opportunity to improve survival.

Is There a Connection Between Diabetes and Psychological Dysfunction?

This review discusses evidence-based perspectives on the relationship between diabetes and psychological distress. Future directions for inquiry and clinical management also are addressed.

Co-occurring medical and mental illness and substance use disorders among veteran clinic users with spinal cord injury patients with complexities

STUDY DESIGN

Longitudinal analysis of SCI registry merged with VHA administrative-data and Medicare claims files (FY1999-2002).

OBJECTIVES

To estimate the prevalence of mental illness (MI) and substance use disorders (SUDs) among veteran health administration (VHA) clinic users with spinal cord injuries (SCI) and examine subgroup variations by demographic, socioeconomic characteristics, and duration and level of SCI.

SETTING

VHA clinic users (N=8338) with SCI who were alive by the end of FY2002.

METHODS

ICD-9-CM codes were used to identify individual MI (anxiety disorders, bipolar, depressive disorders, psychoses, post-traumatic stress disorder (PTSD) and schizophrenia) and categories of SUDs (tobacco, alcohol and drug abuse). Chi-square tests and multinomial logistic regression were used to examine the demographic and socio-economic profile of VHA users with SCI and MI and/or SUD.

RESULTS

Over a 2-year period, 46% VHA users with SCI had either a MI or SUDs: 20% had MI only; 12% had SUD only and 14% had both. The most common MI was depressive disorder (27%) and tobacco use was highly prevalent (19%). African-Americans (versus whites) were less likely to be diagnosed with MI only. Increased duration of SCI lowered the likelihood of MI and/or SUDs. Mood and anxiety disorders were highly prevalent in veterans with SCI with chronic physical conditions such as diabetes, heart disease, hypertension, and respiratory diseases.

CONCLUSIONS

Mental illness and SUDs are highly prevalent in the VHA population with SCI and is complicated by the high rates of chronic physical conditions, presenting challenges in their healthcare management.

Expenditures in mental illness and substance use disorders among veteran clinic users with diabetes

Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the "No MI and No SUD" and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.