1
|
Ray WA, Fuchs DC, Olfson M, Stein CM, Murray KT, Daugherty J, Cooper WO. Incidence of Neuroleptic Malignant Syndrome During Antipsychotic Treatment in Children and Youth: A National Cohort Study. J Child Adolesc Psychopharmacol 2024. [PMID: 39268665 DOI: 10.1089/cap.2024.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Objective: The incidence of neuroleptic malignant syndrome (NMS), a rare, potentially fatal adverse effect of antipsychotics, among children and youth is unknown. This cohort study estimated NMS incidence in antipsychotic users age 5-24 years and described its variation according to patient and antipsychotic characteristics. Methods: We used national Medicaid data (2004-2013) to identify patients beginning antipsychotic treatment and calculated the incidence of NMS during antipsychotic current use. Adjusted hazard ratios (HRs) assessed the independent contribution of patient and antipsychotic characteristics to NMS risk. Results: The 1,032,084 patients had 131 NMS cases during 1,472,558 person-years of antipsychotic current use, or 8.9 per 100,000 person-years. The following five factors independently predicted increased incidence: age 18-24 years (HR [95% CI] = 2.45 [1.65-3.63]), schizophrenia spectrum and other psychotic disorders (HR = 5.86 [3.16-10.88]), neurodevelopmental disorders (HR = 7.11 [4.02-12.56]), antipsychotic dose >200mg chlorpromazine-equivalents (HR = 1.71 [1.15-2.54]), and first-generation antipsychotics (HR = 4.32 [2.74-6.82]). NMS incidence per 100,000 person-years increased from 1.8 (1.1-3.0) for those with none of these factors to 198.1 (132.8-295.6) for those with 4 or 5 factors. Findings were essentially unchanged in sensitivity analyses that restricted the study data to second-generation antipsychotics, children age 5-17 years, and the 5 most recent calendar years. Conclusion: In children and youth treated with antipsychotics, five factors independently identified patients with increased NMS incidence: age 18-24 years, schizophrenia spectrum and other psychotic disorders, neurodevelopmental disorders, first-generation drugs, and antipsychotic doses greater than 200 mg chlorpromazine-equivalents. Patients with 4 or 5 of these factors had more than 100 times the incidence of those with none. These findings could improve early identification of children and youth with elevated NMS risk, potentially leading to earlier detection and improved outcomes.
Collapse
Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - D Catherine Fuchs
- Department of Psychiatry and Behavioral Science, Division of Child and Adolescent Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Olfson
- New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, New York, USA
| | - Charles M Stein
- Department of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Katherine T Murray
- Department of Medicine and Pharmacology, Divisions of Clinical Pharmacology and Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - William O Cooper
- Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Hwong AR, Murphy KA, Vittinghoff E, Alonso-Fraire P, Crystal S, Walkup J, Hermida R, Olfson M, Cournos F, Sawaya GF, Mangurian C. Cervical Cancer Screening Among Female Medicaid Beneficiaries With and Without Schizophrenia. Schizophr Bull 2024:sbae096. [PMID: 38842724 DOI: 10.1093/schbul/sbae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND AND HYPOTHESIS In the United States, women with schizophrenia face challenges in receiving gynecologic care, but little is known about how cervical cancer screening rates vary across time or states in a publicly insured population. We hypothesized that women Medicaid beneficiaries with schizophrenia would be less likely to receive cervical cancer screening across the United States compared with a control population, and that women with schizophrenia and other markers of vulnerability would be least likely to receive screening. STUDY DESIGN This retrospective cohort study used US Medicaid administrative data from across 44 states between 2002 and 2012 and examined differences in cervical cancer screening test rates among 283 950 female Medicaid beneficiaries with schizophrenia and a frequency-matched control group without serious mental illness, matched on age and race/ethnicity. Among women with schizophrenia, multivariable logistic regression estimated the odds of receiving cervical cancer screening using individual sociodemographics, comorbid conditions, and health care service utilization. STUDY RESULTS Compared to the control group, women with schizophrenia were less likely to receive cervical cancer screening (OR = 0.76; 95% CI 0.75-0.77). Among women with schizophrenia, nonwhite populations, younger women, urban dwellers, those with substance use disorders, anxiety, and depression and those connected to primary care were more likely to complete screening. CONCLUSIONS Cervical cancer screening rates among US women Medicaid beneficiaries with schizophrenia were suboptimal. To address cervical cancer care disparities for this population, interventions are needed to prioritize women with schizophrenia who are less engaged with the health care system or who reside in rural areas.
Collapse
Affiliation(s)
- Alison R Hwong
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, Mental Health Service, San Francisco, CA, USA
| | - Karly A Murphy
- Department of Medicine, UCSF Division of General Internal Medicine, San Francisco, CA, USA
| | - Eric Vittinghoff
- UCSF Department of Epidemiology and Biostatistics, San Francisco, CA, USA
| | - Paola Alonso-Fraire
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Jamie Walkup
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Richard Hermida
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Mark Olfson
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Francine Cournos
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - George F Sawaya
- UCSF Department of Epidemiology and Biostatistics, San Francisco, CA, USA
- UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
- UCSF Philip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
| | - Christina Mangurian
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- UCSF Department of Epidemiology and Biostatistics, San Francisco, CA, USA
- UCSF Philip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| |
Collapse
|
3
|
Stewart AJ, Patten SB, Fiest KM, Williamson TS, Wick JP, Ronksley PE. Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis. Health Serv Insights 2023; 16:11786329231183317. [PMID: 37377884 PMCID: PMC10291413 DOI: 10.1177/11786329231183317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of "high-cost" adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.
Collapse
Affiliation(s)
- Andrew J Stewart
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Calgary, Canada
| | - Scott B Patten
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Calgary, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kirsten M Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Calgary, Canada
| | - Tyler S Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Calgary, Canada
| | - James P Wick
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Calgary, Canada
| |
Collapse
|
4
|
Stewart AJ, Patten SB, Fiest KM, Williamson TS, Wick JP, Ronksley PE. 10-Year Trends in Healthcare Spending among Patients with Schizophrenia in Alberta, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:723-733. [PMID: 35244485 PMCID: PMC9449136 DOI: 10.1177/07067437221082885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Schizophrenia is characterized by high levels of disability often resulting in increased healthcare utilization and spending. With expanding healthcare costs across all healthcare sectors, there is a need to understand how healthcare spending has changed over time. We conducted a population-based study using administrative health data from Alberta, Canada, to describe changes in medical complexity and direct healthcare spending among patients with schizophrenia over a 10-year period. METHODS A serial cross-sectional study from January 1, 2008, to December 31, 2017, was conducted to determine changes in demographic characteristics, medical complexity, and costs among all adults (18 years or older) with schizophrenia. Total healthcare spending and sector-specific costs attributable to hospitalizations, emergency department visits, practitioner billings, and prescriptions were calculated and compared over time. RESULTS Over the 10-year period the contact prevalence of patients with schizophrenia increased from 0.6% (n = 16,183) to 1.0% (n = 33,176) within the province. There was a marked change in medical complexity with the number of patients living with 3 or more comorbidities increasing from 33.0% to 47.3%. Direct annual healthcare costs increased 2-fold from 321 to 639 million CAD (493 million USD) with a 7-fold increase in medication expenditures over the 10-year time frame. As of 2017, spending on pharmaceutical treatment surpassed hospitalizations as the leading spending category in this population. CONCLUSIONS Healthcare spending among patients with schizophrenia continues to increase and may be partially attributable to growing rates of multimorbidity within this population. Although promising second-generation antipsychotic medications have entered the market, this has resulted in considerable changes in the distribution of healthcare spending over time. These findings will inform policy discussions around resource allocation and efforts to curb health spending while also improving care for patients with schizophrenia.
Collapse
Affiliation(s)
- Andrew J Stewart
- Department of Community Health Sciences, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| | - Scott B Patten
- Department of Community Health Sciences, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada.,Department of Medicine, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| | - Kirsten M Fiest
- Department of Community Health Sciences, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| | - Tyler S Williamson
- Department of Community Health Sciences, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| | - James P Wick
- Department of Medicine, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, 2129University of Calgary, Calgary, Canada
| |
Collapse
|
5
|
Llamocca EN, Fristad MA, Bridge JA, Brock G, Steelesmith DL, Axelson DA, Fontanella CA. Correlates of deliberate self-harm among youth with bipolar disorder. J Affect Disord 2022; 302:376-384. [PMID: 35066010 PMCID: PMC8957063 DOI: 10.1016/j.jad.2022.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/15/2021] [Accepted: 01/19/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Youth with bipolar disorder (BD) are at high risk for deliberate self-harm (DSH) and suicide. However, research regarding factors associated with DSH, a key suicide risk factor, among youth with BD is limited. In a population-based sample of youth with BD, we therefore investigated associations between demographic, clinical, and service utilization factors and DSH incidence and compared suicide, unintentional injury, and all-cause mortality to the general population. METHOD We analyzed a retrospective cohort of youth aged 5 to 19 years with a new BD episode between 2010 and 2017 (n = 25,244) using Ohio Medicaid claims and death certificate data. Cox proportional hazards models examined associations between different factors and DSH. Mortality rates were compared to the general population using standardized mortality ratios. RESULTS During follow-up, 1,517 (6.0%) youth had at least one DSH event. Older index age, female sex, comorbid psychiatric/medical conditions, prior DSH/suicidal ideation, and prior ER mental healthcare were associated with increased DSH risk. Prior DSH was most strongly associated with increased DSH risk for 3 months after a new BD episode. Being non-Hispanic Black (vs. White, non-Hispanic) and prior psychiatric hospitalization were associated with decreased DSH hazard. DSH risk was highest for 3 months after a new BD episode. Suicide, unintentional injury, and all-cause mortality rates were elevated in youth with BD. LIMITATIONS May not generalize to other states or non-Medicaid populations; claims data cannot distinguish suicidal intent of self-harm CONCLUSION: Early intervention following a new BD episode, particularly among high-risk groups, is key to prevent DSH.
Collapse
Affiliation(s)
- Elyse N Llamocca
- Division of Epidemiology, The Ohio State University, Columbus, OH, USA; Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - Mary A Fristad
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA; Big Lots Behavioral Health Services and Division of Child and Family Psychiatry, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffrey A Bridge
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA; Center for Suicide Prevention and Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Guy Brock
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Danielle L Steelesmith
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - David A Axelson
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA; Department of Psychiatry, Nationwide Children's Hospital, Columbus, OH, USA
| | - Cynthia A Fontanella
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA.
| |
Collapse
|
6
|
Horvitz-Lennon M, Volya R, Hollands S, Zelevinsky K, Mulcahy A, Donohue JM, Normand SLT. Factors Associated With Off-Label Utilization of Second-Generation Antipsychotics Among Publicly Insured Adults. Psychiatr Serv 2021; 72:1031-1039. [PMID: 34074139 PMCID: PMC8410611 DOI: 10.1176/appi.ps.202000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Off-label utilization of second-generation antipsychotic medications may expose patients to significant risks. The authors examined the prevalence, temporal trends, and factors associated with off-label utilization of second-generation antipsychotics among publicly insured adults. METHODS A retrospective repeated panel was used to examine monthly off-label utilization of second-generation antipsychotics among fee-for-service Medicare, Medicaid, and dually eligible White, Black, and Latino adult beneficiaries filling prescriptions for second-generation antipsychotics in California, Georgia, Mississippi, and Oklahoma from July 2008 through June 2013. RESULTS Among 301,367 users of second-generation antipsychotics, between 36.5% and 41.9% had utilization that was always off-label. Payer did not modify effects of race-ethnicity on off-label utilization. Compared with Whites, Blacks had lower monthly odds of off-label utilization in all four states, and Latinos had lower odds of utilization in California and Georgia. Payer was associated with off-label utilization in California, Mississippi, and Oklahoma. California Medicaid beneficiaries were 1.12 (95% confidence interval=1.10-1.13) times as likely as dually eligible beneficiaries to have off-label utilization. Off-label utilization increased relative to the baseline year in all states, but a downward trend followed in three states. CONCLUSIONS Off-label utilization of second-generation antipsychotics was prevalent despite the drugs' cardiometabolic risks and little evidence of their effectiveness. The lower likelihood of off-label utilization among patients from racial-ethnic minority groups might stem from prescribers' efforts to minimize risks, given a higher baseline risk for these groups, or from disparities-associated factors. Variation among payers suggests that payer policies can affect off-label utilization.
Collapse
Affiliation(s)
- Marcela Horvitz-Lennon
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Rita Volya
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Simon Hollands
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Katya Zelevinsky
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Andrew Mulcahy
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Julie M Donohue
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Sharon-Lise T Normand
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| |
Collapse
|
7
|
Avoundjian T, Troszak L, Cave S, Shimada S, McInnes K, Midboe AM. Correlates of personal health record registration and utilization among veterans with HIV. JAMIA Open 2021; 4:ooab029. [PMID: 34278241 DOI: 10.1093/jamiaopen/ooab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 03/05/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objective We examined correlates of registration and utilization of the Veteran Health Administration's (VHA) personal health record (PHR), My HealtheVet (MHV), among a national cohort of veterans living with HIV. Materials and Methods Using VHA administrative data, we matched veterans with HIV who registered for MHV in fiscal year 2012-2018 (n = 8589) to 8589 veterans with HIV who did not register for MHV. We compared demographic and geographic characteristics, housing status, comorbidities, and non-VHA care between MHV registrants and nonregistrants to identify correlates of MHV registration. Among registrants, we examined the association between these characteristics and MHV tool use (prescription refill, record download, secure messaging, view labs, and view appointments). Results MHV registrants were more likely to be younger, women, White, and to have bipolar disorder, depression, or post-traumatic stress disorder diagnosis than nonregistrants. Having a substance use disorder (SUD) diagnosis or a higher Elixhauser score was associated with lower odds of MHV registration. Among registrants, women were less likely to use prescription refill. Patients who were at risk of homelessness in the past year were less likely to use secure messaging and, along with those who were homeless, were less likely to use view labs and prescription refill. Bipolar disorder and depression were associated with increased secure messaging use. Diagnoses of SUD and alcohol use disorder were both associated with lower rates of prescription refill. Discussion Among veterans living with HIV, we identified significant differences in PHR registration and utilization by race, sex, age, housing status, and diagnosis.
Collapse
Affiliation(s)
- Tigran Avoundjian
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA.,Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Lara Troszak
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA.,Stanford School of Medicine, Stanford University, Stanford, California, USA
| | - Shayna Cave
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA.,Stanford School of Medicine, Stanford University, Stanford, California, USA
| | - Stephanie Shimada
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Keith McInnes
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA.,Stanford School of Medicine, Stanford University, Stanford, California, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| |
Collapse
|
8
|
Brandt CA, Workman TE, Farmer MM, Akgün KM, Abel EA, Skanderson M, Bean-Mayberry B, Zeng-Treitler Q, Mason M, Bastian LA, Goulet JL, Post LA. Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study. West J Emerg Med 2021; 22:525-532. [PMID: 34125022 PMCID: PMC8203018 DOI: 10.5811/westjem.2021.4.51203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. METHODS The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. RESULTS The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). CONCLUSION Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.
Collapse
Affiliation(s)
- Cynthia A. Brandt
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - T. Elizabeth Workman
- The George Washington University, Biomedical Informatics Center, Washington, District of Columbia
- VA Medical Center, Washington, District of Columbia
| | - Melissa M. Farmer
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Kathleen M. Akgün
- VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Erica A. Abel
- VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Department of Psychiatry, New Haven, Connecticut
| | | | - Bevanne Bean-Mayberry
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- UCLA David Geffen School of Medicine, Department of Medicine, Los Angeles, California
| | - Qing Zeng-Treitler
- The George Washington University, Biomedical Informatics Center, Washington, District of Columbia
- VA Medical Center, Washington, District of Columbia
| | - Maryann Mason
- Northwestern University, Department of Emergency Medicine, Chicago, Illinois
| | - Lori A. Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Joseph L. Goulet
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A. Post
- Northwestern University, Department of Emergency Medicine, Chicago, Illinois
- Northwestern University, Department of Geriatric Medicine, Chicago, Illinois
| |
Collapse
|
9
|
Alexander-Bloch AF, Raznahan A, Shinohara RT, Mathias SR, Bathulapalli H, Bhalla IP, Goulet JL, Satterthwaite TD, Bassett DS, Glahn DC, Brandt CA. The architecture of co-morbidity networks of physical and mental health conditions in military veterans. Proc Math Phys Eng Sci 2020; 476:20190790. [PMID: 32831602 DOI: 10.1098/rspa.2019.0790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 06/03/2020] [Indexed: 11/12/2022] Open
Abstract
Co-morbidity between medical and psychiatric conditions is commonly considered between individual pairs of conditions. However, an important alternative is to consider all conditions as part of a co-morbidity network, which encompasses all interactions between patients and a healthcare system. Analysis of co-morbidity networks could detect and quantify general tendencies not observed by smaller-scale studies. Here, we investigate the co-morbidity network derived from longitudinal healthcare records from approximately 1 million United States military veterans, a population disproportionately impacted by psychiatric morbidity and psychological trauma. Network analyses revealed marked and heterogenous patterns of co-morbidity, including a multi-scale community structure composed of groups of commonly co-morbid conditions. Psychiatric conditions including posttraumatic stress disorder were strong predictors of future medical morbidity. Neurological conditions and conditions associated with chronic pain were particularly highly co-morbid with psychiatric conditions. Across conditions, the degree of co-morbidity was positively associated with mortality. Co-morbidity was modified by biological sex and could be used to predict future diagnostic status, with out-of-sample prediction accuracy of 90-92%. Understanding complex patterns of disease co-morbidity has the potential to lead to improved designs of systems of care and the development of targeted interventions that consider the broader context of mental and physical health.
Collapse
Affiliation(s)
- Aaron F Alexander-Bloch
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.,Department of Child and Adolescent Psychiatry and Behavioral Science, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Armin Raznahan
- Developmental Neurogenomics Unit, Human Genetics Branch, National Institute of Mental Health, Intramural Program, Bethesda, MA, USA
| | - Russell T Shinohara
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Samuel R Mathias
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Harini Bathulapalli
- US Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA.,Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, USA
| | - Ish P Bhalla
- National Clinician Scholars Program, University of California, Los Angeles, CA, USA
| | - Joseph L Goulet
- US Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA.,Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, USA
| | | | - Danielle S Bassett
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA.,Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA.,Santa Fe Institute, Santa Fe, NM, USA
| | - David C Glahn
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Cynthia A Brandt
- US Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA.,Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
10
|
The role of physical pain in global functioning of people with serious mental illness. Schizophr Res 2020; 222:423-428. [PMID: 32499163 DOI: 10.1016/j.schres.2020.03.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 01/16/2020] [Accepted: 03/28/2020] [Indexed: 11/23/2022]
Abstract
While people with serious mental illness (SMI) endorse clinical pain at rates on par or exceeding those in the general population, the association between pain and functioning remains unclear. In this paper we present data on the cross-sectional association between clinical pain and global functioning in a large, mixed diagnostic sample of people with SMI. Eight-hundred ninety-eight people diagnosed with bipolar disorder, major depressive disorder, or schizophrenia were administered the Global Assessment Scale and the 12-item Short Form Survey, which includes an assessment of the extent to which the experience of pain interfered with daily activities over the past month. People with major depressive disorder reported higher pain interference than those with schizophrenia and bipolar disorder. The presence of physical health conditions and psychiatric symptoms were also assessed. After controlling for age, gender, psychiatric symptoms, education level, and physical health problems, pain interference in the past month was associated with significantly lower global functioning. The findings suggest that the experience of pain is associated with poorer global functioning across major SMI diagnoses. Moreover, the impact of pain in global functioning appears independent of physical health problems, and thus may warrant routine screening from mental health providers.
Collapse
|
11
|
Abstract
BACKGROUND Recent reports of increased national estimates of pediatric psychiatric emergency department (ED) visits and psychiatric hospitalizations emphasize the need to research these utilization patterns. OBJECTIVES To assess the patient-provider continuity of care (CoC) and compare the risk of psychiatric ED visits or hospitalization according to the CoC level. RESEARCH DESIGN A cohort design was applied to Medicaid administrative claims data (2007-2014) for 3-16-year olds with a first psychiatric diagnosis between 2009 and 2013 (n=38,825). SUBJECTS Continuously enrolled youths with (1) ≥1 outpatient psychiatric visits and (2) ≥4 pediatric outpatient visits in the prior 24 months. MEASURES The authors assessed CoC in the 24 months before the first psychiatric outpatient visit and quantified CoC using the Alpha Index. The authors assessed patient-provider CoC before first psychiatric diagnosis and the odds of psychiatric ED visits or psychiatric hospitalizations in the year after diagnosis. RESULTS Of the 38,825 youths, 88.9% received a first psychiatric diagnosis by age 14. The odds of ED visits were significantly higher among youths with low CoC [6.63%, adjusted odds ratio (AOR), 1.27; 95% confidence interval (CI), 1.13-1.41] or moderate CoC (5.76%; AOR, 1.14; 95% CI, 1.02-1.27) compared with those with high CoC (4.96%). Greater odds of psychiatric hospitalization related to low (7.53%; AOR, 1.17; 95% CI, 1.06-1.29) or moderate CoC (7.01%; AOR, 1.15; 95% CI, 1.03-1.27) compared with high CoC (6.06%). CONCLUSIONS The odds of potentially disruptive clinical management and costly psychiatric ED visits or hospitalizations were lower for youths with high CoC. The findings support the need to research the impact of CoC on long-term pediatric mental health service use.
Collapse
|
12
|
Gruschow SM, Yerys BE, Power TJ, Durbin DR, Curry AE. Validation of the Use of Electronic Health Records for Classification of ADHD Status. J Atten Disord 2019; 23:1647-1655. [PMID: 28112025 PMCID: PMC5843549 DOI: 10.1177/1087054716672337] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To validate an electronic health record (EHR)-based algorithm to classify ADHD status of pediatric patients. METHOD As part of an applied study, we identified all primary care patients of The Children's Hospital of Philadelphia [CHOP] health care network who were born 1987-1995 and residents of New Jersey. Patients were classified with ADHD if their EHR indicated an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of "314.x" at a clinical visit or on a list of known conditions. We manually reviewed EHRs for ADHD patients ( n = 2,030) and a random weighted sample of non-ADHD patients ( n = 807 of 13,579) to confirm the presence or absence of ADHD. RESULTS Depending on assumptions for inconclusive cases, sensitivity ranged from 0.96 to 0.97 (95% confidence interval [CI] = [0.95, 0.97]), specificity from 0.98 to 0.99 [0.97, 0.99], and positive predictive value from 0.83 to 0.98 [0.81, 0.99]. CONCLUSION EHR-based diagnostic codes can accurately classify ADHD status among pediatric patients and can be used by large-scale epidemiologic and clinical studies with high sensitivity and specificity.
Collapse
Affiliation(s)
| | - Benjamin E Yerys
- 1 The Children's Hospital of Philadelphia, PA, USA
- 2 University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas J Power
- 1 The Children's Hospital of Philadelphia, PA, USA
- 2 University of Pennsylvania, Philadelphia, PA, USA
| | - Dennis R Durbin
- 1 The Children's Hospital of Philadelphia, PA, USA
- 2 University of Pennsylvania, Philadelphia, PA, USA
| | | |
Collapse
|
13
|
Abel EA, Shimada SL, Wang K, Ramsey C, Skanderson M, Erdos J, Godleski L, Houston TK, Brandt CA. Dual Use of a Patient Portal and Clinical Video Telehealth by Veterans with Mental Health Diagnoses: Retrospective, Cross-Sectional Analysis. J Med Internet Res 2018; 20:e11350. [PMID: 30404771 PMCID: PMC6249500 DOI: 10.2196/11350] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/03/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022] Open
Abstract
Background Access to mental health care is challenging. The Veterans Health Administration (VHA) has been addressing these challenges through technological innovations including the implementation of Clinical Video Telehealth, two-way interactive and synchronous videoconferencing between a provider and a patient, and an electronic patient portal and personal health record, My HealtheVet. Objective This study aimed to describe early adoption and use of My HealtheVet and Clinical Video Telehealth among VHA users with mental health diagnoses. Methods We conducted a retrospective, cross-sectional analysis of early My HealtheVet adoption and Clinical Video Telehealth engagement among veterans with one or more mental health diagnoses who were VHA users from 2007 to 2012. We categorized veterans into four electronic health (eHealth) technology use groups: My HealtheVet only, Clinical Video Telehealth only, dual users who used both, and nonusers of either. We examined demographic characteristics and mental health diagnoses by group. We explored My HealtheVet feature use among My HealtheVet adopters. We then explored predictors of My HealtheVet adoption, Clinical Video Telehealth engagement, and dual use using multivariate logistic regression. Results Among 2.17 million veterans with one or more mental health diagnoses, 1.51% (32,723/2,171,325) were dual users, and 71.72% (1,557,218/2,171,325) were nonusers of both My HealtheVet and Clinical Video Telehealth. African American and Latino patients were significantly less likely to engage in Clinical Video Telehealth or use My HealtheVet compared with white patients. Low-income patients who met the criteria for free care were significantly less likely to be My HealtheVet or dual users than those who did not. The odds of Clinical Video Telehealth engagement and dual use decreased with increasing age. Women were more likely than men to be My HealtheVet or dual users but less likely than men to be Clinical Video Telehealth users. Patients with schizophrenia or schizoaffective disorder were significantly less likely to be My HealtheVet or dual users than those with other mental health diagnoses (odds ratio, OR 0.50, CI 0.47-0.53 and OR 0.75, CI 0.69-0.80, respectively). Dual users were younger (53.08 years, SD 13.7, vs 60.11 years, SD 15.83), more likely to be white, and less likely to be low-income than the overall cohort. Although rural patients had 17% lower odds of My HealtheVet adoption compared with urban patients (OR 0.83, 95% CI 0.80-0.87), they were substantially more likely than their urban counterparts to engage in Clinical Video Telehealth and dual use (OR 2.45, 95% CI 1.95-3.09 for Clinical Video Telehealth and OR 2.11, 95% CI 1.81-2.47 for dual use). Conclusions During this study (2007-2012), use of these technologies was low, leaving much potential for growth. There were sociodemographic disparities in access to My HealtheVet and Clinical Video Telehealth and in dual use of these technologies. There was also variation based on types of mental health diagnosis. More research is needed to ensure that these and other patient-facing eHealth technologies are accessible and effectively used by all vulnerable patients.
Collapse
Affiliation(s)
- Erica A Abel
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Stephanie L Shimada
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States.,Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Karen Wang
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Christine Ramsey
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Joseph Erdos
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Linda Godleski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States.,National Telemental Health Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Thomas K Houston
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.,Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
14
|
Pennap D, Zito JM, Santosh PJ, Tom SE, Onukwugha E, Magder LS. Patterns of Early Mental Health Diagnosis and Medication Treatment in a Medicaid-Insured Birth Cohort. JAMA Pediatr 2018; 172:576-584. [PMID: 29710205 PMCID: PMC6137539 DOI: 10.1001/jamapediatrics.2018.0240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE The increased use of psychiatric services in the US pediatric population raises concerns about the appropriate use of psychotropic medications for very young children. OBJECTIVE To assess the longitudinal patterns of psychotropic medication use in association with diagnosis and duration of use in a Medicaid-insured birth cohort. DESIGN, SETTING, AND PARTICIPANTS A cohort design was applied to computerized Medicaid administrative claims data for 35 244 children born in a mid-Atlantic state in 2007 and followed up for up to 96 months through December 31, 2014. Children were included in the birth cohort if they had an enrollment record at birth or within 3 months of birth and at least 6 months of continuous enrollment from birth. The cohort represents 92.2% of 38 225 Medicaid-insured newborns in 2007. EXPOSURES Mental health treatments from birth through age 7 years. MAIN OUTCOMES AND MEASURES Cumulative incidence of first psychiatric diagnosis and psychotropic medication use (monotherapy or concomitant use of psychotropic medications) from birth through age 7 years, total and by sex, and the cumulative incidence of the use of psychosocial services (age, 0-7 years) as well as the annual duration of medication use (ie, number of days of psychotropic medication use among children 3-7 years of age). RESULTS Of the 35 244 children in the cohort, 17 267 were girls and 17 977 were boys. By age 8 years, 4550 children in the birth cohort (19.7% [percentage adjusted for right censoring]) had received a psychiatric diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 290-319); 2624 of these diagnoses (57.7%) were behavioral (codes 312, 313, or 314). Girls were more likely than boys to receive an incident psychiatric diagnosis of adjustment disorder (355 of 1598 [22.2%] vs 427 of 2952 [14.5%]; P < .001) or anxiety disorder (114 of 1598 [7.1%] vs 120 of 2952 [4.1%]; P < .001). By age 8 years, 2196 children in the cohort (10.2% [percentage adjusted for right censoring]) had received a psychotropic medication. Among medication users, 1763 of 2196 (80.5% [percentage adjusted for right censoring]) received monotherapy, 343 of 2196 (16.4% [percentage adjusted for right censoring]) received 2 medication classes concomitantly, and 90 of 2196 (4.3% [percentage adjusted for right censoring]) received 3 or more medication classes concomitantly for 60 days or more (range, 78-180 days). The annual median number of days of psychotropic medication use among medicated children increased with age, reaching 210 of 365 days for children 7 years of age. Among children 7 years of age, the median number of days of use of an antipsychotic (193 days [interquartile range, 60-266 days]), stimulant (183 days [interquartile range, 86-295 days]), or α-agonist (199 days [interquartile range, 85-305 days]) exceeded half of the year. CONCLUSIONS AND RELEVANCE Medicaid-insured children received substantial mental health services and had prolonged exposure to psychotropic medications in the early years of life. These findings highlight the need for outcomes research in pediatric populations.
Collapse
Affiliation(s)
- Dinci Pennap
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore
| | - Julie M. Zito
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore,Department of Psychiatry, University of Maryland, Baltimore
| | - Paramala J. Santosh
- Centre for Interventional Pediatric Psychopharmacology and Rare Diseases, Maudsley Hospital, London, United Kingdom
| | - Sarah E. Tom
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore
| | - Laurence S. Magder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| |
Collapse
|
15
|
Is Mental Illness a Risk Factor for Hospital Readmission? ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 45:933-943. [PMID: 29796933 DOI: 10.1007/s10488-018-0874-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
People with mental illnesses (MI) receive suboptimal care for medical comorbidities and their high risk for readmission may be addressed by adequate medication management and follow-up care. We examined the association between MI, medication changes, and post-discharge outpatient visits with 30-day readmission in 40,048 Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure or pneumonia. Beneficiaries with MI were more likely to be readmitted than those without MI (14 vs. 11%). Probability of readmission was 13 and 12% when medications were dropped or added, respectively, versus 11% when no change was made. Probability of readmission also increased with outpatient visits.
Collapse
|
16
|
Buta E, Masheb R, Gueorguieva R, Bathulapalli H, Brandt CA, Goulet JL. Posttraumatic stress disorder diagnosis and gender are associated with accelerated weight gain trajectories in veterans during the post-deployment period. Eat Behav 2018; 29:8-13. [PMID: 29413821 PMCID: PMC5935565 DOI: 10.1016/j.eatbeh.2018.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Veterans are disproportionately affected by overweight/obesity and growing evidence suggests that post-deployment is a critical period of accelerated weight gain. OBJECTIVE We explored the relationship between posttraumatic stress disorder (PTSD) diagnosis, gender, and post-deployment weight trajectories among U.S. Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. DESIGN We used Veterans Affairs electronic health record data from 248,089 veterans (87% men) who, after their last deployment, had at least one medical visit between October 2001 and January 2009 and more than one BMI recorded through September 2010. We analyzed repeated BMI measurements using linear mixed models, with demographics, PTSD and other relevant psychiatric diagnoses as predictors. RESULTS At the first recorded BMI, veterans' median age was 29, and 59% of women and 77% of men were overweight/obese. They had a median of 6 BMI measurements during a median follow-up of 2.4 years. Controlling for potential confounders, women with a PTSD diagnosis had a yearly BMI growth rate of 0.11 kg/m2 (95% CI 0.09 to 0.13, p < 0.001) higher than women without PTSD. For men, the corresponding PTSD effect was also significant, but slightly lower: 0.07 kg/m2 ((95% CI 0.05 to 0.09, p < 0.001); women-men difference: 0.03 (95% CI 0.01 to 0.06) kg/m2, p = 0.006). CONCLUSIONS The post-deployment period is critical for weight gain, particularly for veterans diagnosed with PTSD and women veterans with PTSD. Efforts are needed to engage post-deployment veterans in weight management services, and to determine whether tailored recruitment/treatment interventions will reduce disparities for veterans with PTSD.
Collapse
Affiliation(s)
- Eugenia Buta
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States; Yale School of Public Health, Department of Biostatistics, New Haven, CT, United States.
| | - Robin Masheb
- Pain Research, Informatics, Multimorbidities and Education (PRIME)
Center, VA Connecticut Healthcare System, West Haven CT,Yale School of Medicine, Department of Psychiatry, New Haven
CT
| | - Ralitza Gueorguieva
- Yale School of Public Health, Department of Biostatistics, New Haven
CT,Yale School of Medicine, Department of Psychiatry, New Haven
CT
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities and Education (PRIME)
Center, VA Connecticut Healthcare System, West Haven CT
| | - Cynthia A. Brandt
- Pain Research, Informatics, Multimorbidities and Education (PRIME)
Center, VA Connecticut Healthcare System, West Haven CT,Yale School of Medicine, Department of Emergency Medicine, New Haven
CT
| | - Joseph L. Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME)
Center, VA Connecticut Healthcare System, West Haven CT,Yale School of Medicine, Department of Psychiatry, New Haven
CT
| |
Collapse
|
17
|
Okamura KH, Benjamin Wolk CL, Kang-Yi CD, Stewart R, Rubin RM, Weaver S, Evans AC, Cidav Z, Beidas RS, Mandell DS. The Price per Prospective Consumer of Providing Therapist Training and Consultation in Seven Evidence-Based Treatments within a Large Public Behavioral Health System: An Example Cost-Analysis Metric. Front Public Health 2018; 5:356. [PMID: 29359126 PMCID: PMC5766669 DOI: 10.3389/fpubh.2017.00356] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/15/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Public-sector behavioral health systems seeking to implement evidence-based treatments (EBTs) may face challenges selecting EBTs given their limited resources. This study describes and illustrates one method to calculate cost related to training and consultation to assist system-level decisions about which EBTs to select. METHODS Training, consultation, and indirect labor costs were calculated for seven commonly implemented EBTs. Using extant literature, we then estimated the diagnoses and populations for which each EBT was indicated. Diagnostic and demographic information from Medicaid claims data were obtained from a large behavioral health payer organization and used to estimate the number of covered people with whom the EBT could be used and to calculate implementation-associated costs per consumer. RESULTS Findings suggest substantial cost to therapists and service systems related to EBT training and consultation. Training and consultation costs varied by EBT, from Dialectical Behavior Therapy at $238.07 to Cognitive Behavioral Therapy at $0.18 per potential consumer served. Total cost did not correspond with the number of prospective consumers served by an EBT. CONCLUSION A cost-metric that accounts for the prospective recipients of a given EBT within a given population may provide insight into how systems should prioritize training efforts. Future policy should consider the financial burden of EBT implementation in relation to the context of the population being served and begin a dialog in creating incentives for EBT use.
Collapse
Affiliation(s)
- Kelsie H. Okamura
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
- State of Hawaii Child and Adolescent Mental Health Division, Honolulu, HI, United States
| | | | - Christina D. Kang-Yi
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca Stewart
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Ronnie M. Rubin
- City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, United States
| | - Shawna Weaver
- City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, United States
| | - Arthur C. Evans
- American Psychological Association, Washington, DC, United States
| | - Zuleyha Cidav
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Rinad S. Beidas
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - David S. Mandell
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
18
|
Pennap D, Burcu M, Safer DJ, Zito JM. Hispanic Residential Isolation, ADHD Diagnosis and Stimulant Treatment among Medicaid-Insured Youth. Ethn Dis 2017; 27:85-94. [PMID: 28439178 DOI: 10.18865/ed.27.2.85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate a conceptual framework that assessed the effect of Hispanic residential isolation on Attention Deficit Hyperactivity Disorder (ADHD) health service utilization among 2.2 million publicly insured youth. DESIGN Cross-sectional. SETTING Medicaid administrative claims data for ambulatory care services from a US Pacific state linked with US census data. PARTICIPANTS Youth, aged 2-17 years, continuously enrolled in 2009. MAIN OUTCOME MEASURES The percent annual prevalence and odds of ADHD diagnosis and stimulant use according to two measures of racial/ethnic residential isolation: 1) the county-level Hispanic isolation index (HI) defined as the population density of Hispanic residents in relation to other racial/ethnic groups in a county (<.5; .5-.64; ≥.65); and 2) the proportion of Hispanic residents in a ZIP code tabulation area (<25%; 25%-50%; >50%). RESULTS Among the 47,364 youth with a clinician-reported ADHD diagnosis, 60% received a stimulant treatment (N = 28,334). As the county level HI increased, Hispanic residents of ethnically isolated locales were significantly less likely to receive an ADHD diagnosis (adjusted odds ratio [AOR]=.92 [95% CI=.88-.96]) and stimulant use (AOR=.61 [95% CI=.59-.64]) compared with Hispanic youth in less isolated areas. At the ZIP code level, a similar pattern of reduced ADHD diagnosis (AOR=.81 [95% CI=.77-.86]) and reduced stimulant use (AOR=.65 [95% CI=.61-.69]) was observed as Hispanic residential isolation increased from the least isolated to the most isolated ZIP code areas. CONCLUSIONS These findings highlight the opportunity for Big Data to advance mental health research on strategies to reduce racial/ethnic health disparities, particularly for poor and vulnerable youth. Further exploration of racial/ethnic residential isolation in other large data sources is needed to guide future policy development and to target culturally sensitive interventions.
Collapse
Affiliation(s)
- Dinci Pennap
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD
| | - Mehmet Burcu
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD
| | - Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Julie M Zito
- Departments of Pharmaceutical Health Services Research and Psychiatry, University of Maryland, Baltimore, MD
| |
Collapse
|
19
|
Westney G, Foreman MG, Xu J, Henriques King M, Flenaugh E, Rust G. Impact of Comorbidities Among Medicaid Enrollees With Chronic Obstructive Pulmonary Disease, United States, 2009. Prev Chronic Dis 2017; 14:E31. [PMID: 28409741 PMCID: PMC5392445 DOI: 10.5888/pcd14.160333] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Multimorbidity, the presence of 2 or more chronic conditions, frequently affects people with chronic obstructive pulmonary disease (COPD). Many have high-cost, highly complex conditions that have a substantial impact on state Medicaid programs. We quantified the cost of Medicaid-insured patients with COPD co-diagnosed with other chronic disorders. METHODS We used nationally representative Medicaid claims data to analyze the impact of comorbidities (other chronic conditions) on the disease burden, emergency department (ED) use, hospitalizations, and total health care costs among 291,978 adult COPD patients. We measured the prevalence of common conditions and their influence on COPD-related and non-COPD-related resource use by using the Elixhauser Comorbidity Index. Elixhauser comorbidity counts were clustered from 0 to 7 or more. We performed multivariable logistic regression to determine the odds of ED visits by Elixhauser scores adjusting for age, sex, race/ethnicity, and residence. RESULTS Acute care, hospital bed days, and total Medicaid-reimbursed costs increased as the number of comorbidities increased. ED visits unrelated to COPD were more common than visits for COPD, especially in patients self-identified as black or African American (designated black). Hypertension, diabetes, affective disorders, hyperlipidemia, and asthma were the most prevalent comorbid disorders. Substance abuse, congestive heart failure, and asthma were commonly associated with ED visits for COPD. Female sex was associated with COPD-related and non-COPD-related ED visits. CONCLUSION Comorbidities markedly increased health services use among people with COPD insured with Medicaid, although ED visits in this study were predominantly unrelated to COPD. Achieving excellence in clinical practice with optimal clinical and economic outcomes requires a whole-person approach to the patient and a multidisciplinary health care team.
Collapse
Affiliation(s)
- Gloria Westney
- Pulmonary and Critical Care Division, Morehouse School of Medicine, Atlanta, Georgia
| | - Marilyn G Foreman
- Pulmonary and Critical Care Division, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30080.
| | - Junjun Xu
- National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Eric Flenaugh
- Pulmonary and Critical Care Division, Morehouse School of Medicine, Atlanta, Georgia
| | - George Rust
- National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
20
|
Chiang CL, Chen PC, Huang LY, Kuo PH, Tung YC, Liu CC, Chen WJ. Time trends in first admission rates for schizophrenia and other psychotic disorders in Taiwan, 1998-2007: a 10-year population-based cohort study. Soc Psychiatry Psychiatr Epidemiol 2017; 52:163-173. [PMID: 28028581 DOI: 10.1007/s00127-016-1326-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/15/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE To examine the trend in annual first admission rates for psychotic disorders as a whole as well as individual psychotic disorders in Taiwan from 1998 to 2007, and influences of age, sex, and geographic region on the trend. METHOD Using the inpatient claims records in the National Health Insurance Research Database, we estimated the yearly first admission rates for schizophrenia and other psychotic disorders, including voluntary (1998-2007) and involuntary (2004-2007) admissions. Both narrow and broad definitions of psychotic disorders were examined. RESULTS While involuntary first admission rates were stable, a crescendo-decrescendo change in voluntary first admission rates for psychotic disorders was observed, peaking in 2001. The increase from 1998 to 2001 was closely associated with health insurance expansion. Before 2001, the voluntary first admission rates in males aged 15-24 were underestimated as military personnel records were not included in the database. From 2001 to 2007, voluntary first admissions for psychotic disorders decreased 38%; the decrease could not be accounted for by the mild diagnostic shifts away from schizophrenia to affective psychosis or substance-induced psychosis. During the entire observation period, first admission rates for schizophrenia decreased 48%, while affective psychosis increased 84%. Gender disparities in the first admission rates gradually diminished, but geographic disparities persisted. CONCLUSIONS First admission rates for psychosis significantly reduced in Taiwan between 1998 and 2007, mainly driven by the reduced hospitalization risk for schizophrenia. Special attention should be paid to the increased hospitalization for other types of psychotic disorders (especially affective psychosis) and the unresolved geographic disparities.
Collapse
Affiliation(s)
- Chih-Lin Chiang
- Master of Public Health Degree Program, College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei, 100, Taiwan.,Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Division of New Drugs, Center for Drug Evaluation, Taipei, Taiwan
| | - Pei-Chun Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Public Health, China Medical University, Taichung, Taiwan
| | - Ling-Ya Huang
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Po-Hsiu Kuo
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei J Chen
- Master of Public Health Degree Program, College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei, 100, Taiwan. .,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan. .,Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
21
|
Burg MM, Brandt C, Buta E, Schwartz J, Bathulapalli H, Dziura J, Edmondson DE, Haskell S. Risk for Incident Hypertension Associated With Posttraumatic Stress Disorder in Military Veterans and the Effect of Posttraumatic Stress Disorder Treatment. Psychosom Med 2017; 79:181-188. [PMID: 27490852 PMCID: PMC5285494 DOI: 10.1097/psy.0000000000000376] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) increases cardiovascular disease and cardiovascular mortality risk. Neither the prospective relationship of PTSD to incident hypertension risk nor the effect of PTSD treatment on hypertension risk has been established. METHODS Data from a nationally representative sample of 194,319 veterans were drawn from the Veterans Administration (VA) roster of United States service men and women. This included veterans whose end of last deployment was from September 2001 to July 2010 and whose first VA medical visit was from October 1, 2001 to January 1, 2009. Incident hypertension was modeled as 3 events: (1) a new diagnosis of hypertension and/or (2) a new prescription for antihypertensive medication, and/or (3) a clinic blood pressure reading in the hypertensive range (≥140/90 mm Hg, systolic/diastolic). Posttraumatic stress disorder diagnosis was the main predictor. Posttraumatic stress disorder treatment was defined as (1) at least 8 individual psychotherapy sessions of 50 minutes or longer during any consecutive 6 months and/or (2) a prescription for selective serotonin reuptake inhibitor medication. RESULTS Over a median 2.4-year follow-up, the incident hypertension risk independently associated with PTSD ranged from hazard ratio (HR), 1.12 (95% confidence interval [CI], 1.08-1.17; p < .0001) to HR, 1.30 (95% CI, 1.26-1.34; p < .0001). The interaction of PTSD and treatment revealed that treatment reduced the PTSD-associated hypertension risk (e.g., from HR, 1.44 [95% CI, 1.38-1.50; p < .0001] for those untreated, to HR, 1.20 [95% CI, 1.15-1.25; p < .0001] for those treated). CONCLUSIONS These results indicate that reducing the long-term health impact of PTSD and the associated costs may require very early surveillance and treatment.
Collapse
Affiliation(s)
- Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, CT,Yale University School of Medicine, New Haven, CT,Center for Behavioral Cardiovascular Health, Columbia University School of Medicine, New York, NY
| | - Cynthia Brandt
- VA Connecticut Healthcare System, West Haven, CT,Yale University School of Medicine, New Haven, CT
| | - Eugenia Buta
- VA Connecticut Healthcare System, West Haven, CT,Yale University School of Medicine, New Haven, CT
| | - Joseph Schwartz
- Center for Behavioral Cardiovascular Health, Columbia University School of Medicine, New York, NY
| | | | - James Dziura
- Yale University School of Medicine, New Haven, CT
| | - Donald E. Edmondson
- Center for Behavioral Cardiovascular Health, Columbia University School of Medicine, New York, NY
| | - Sally Haskell
- VA Connecticut Healthcare System, West Haven, CT,Yale University School of Medicine, New Haven, CT
| |
Collapse
|
22
|
Ramsey C, Dziura J, Justice AC, Altalib HH, Bathulapalli H, Burg M, Decker S, Driscoll M, Goulet J, Haskell S, Kulas J, Wang KH, Mattocks K, Brandt C. Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001-2014. Am J Public Health 2016; 107:329-335. [PMID: 27997229 DOI: 10.2105/ajph.2016.303574] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate gender, age, and race/ethnicity as predictors of incident mental health diagnoses among Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. METHODS We used US Veterans Health Administration (VHA) electronic health records from 2001 to 2014 to examine incidence rates and sociodemographic risk factors for mental health diagnoses among 888 142 veterans. RESULTS Posttraumatic stress disorder (PTSD) was the most frequently diagnosed mental health condition across gender and age groups. Incidence rates for all mental health diagnoses were highest at ages 18 to 29 years and declined thereafter, with the exceptions of major depressive disorder (MDD) in both genders, and PTSD among women. Risk of incident bipolar disorder and MDD diagnoses were greater among women; risk of incident schizophrenia, and alcohol- and drug-use disorders diagnoses were greater in men. Compared with Whites, risk incident PTSD, MDD, and alcohol-use disorder diagnoses were lower at ages 18 to 29 years and higher at ages 45 to 64 years for both Hispanics and African Americans. CONCLUSIONS Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.
Collapse
Affiliation(s)
- Christine Ramsey
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - James Dziura
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Amy C Justice
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Hamada Hamid Altalib
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Harini Bathulapalli
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Matthew Burg
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Suzanne Decker
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Mary Driscoll
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Joseph Goulet
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Sally Haskell
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Joseph Kulas
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Karen H Wang
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Kristen Mattocks
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| | - Cynthia Brandt
- Christine M. Ramsey, Amy C. Justice, Hamada Hamid Altalib, Harini Bathulapalli, Matthew Burg, Suzanne Decker, Mary Driscoll, Joseph Goulet, Sally Haskell, Joseph Kulas, Karen H. Wang, Kristin Mattocks, and Cynthia Brandt are with VA Connecticut Health Care System, West Haven, CT, and Yale University Medical School, New Haven, CT. James Dziura is with Yale University Medical School
| |
Collapse
|
23
|
Davis KAS, Sudlow CLM, Hotopf M. Can mental health diagnoses in administrative data be used for research? A systematic review of the accuracy of routinely collected diagnoses. BMC Psychiatry 2016; 16:263. [PMID: 27455845 PMCID: PMC4960739 DOI: 10.1186/s12888-016-0963-x] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/05/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is increasing availability of data derived from diagnoses made routinely in mental health care, and interest in using these for research. Such data will be subject to both diagnostic (clinical) error and administrative error, and so it is necessary to evaluate its accuracy against a reference-standard. Our aim was to review studies where this had been done to guide the use of other available data. METHODS We searched PubMed and EMBASE for studies comparing routinely collected mental health diagnosis data to a reference standard. We produced diagnostic category-specific positive predictive values (PPV) and Cohen's kappa for each study. RESULTS We found 39 eligible studies. Studies were heterogeneous in design, with a wide range of outcomes. Administrative error was small compared to diagnostic error. PPV was related to base rate of the respective condition, with overall median of 76 %. Kappa results on average showed a moderate agreement between source data and reference standard for most diagnostic categories (median kappa = 0.45-0.55); anxiety disorders and schizoaffective disorder showed poorer agreement. There was no significant benefit in accuracy for diagnoses made in inpatients. CONCLUSIONS The current evidence partly answered our questions. There was wide variation in the quality of source data, with a risk of publication bias. For some diagnoses, especially psychotic categories, administrative data were generally predictive of true diagnosis. For others, such as anxiety disorders, the data were less satisfactory. We discuss the implications of our findings, and the need for researchers to validate routine diagnostic data.
Collapse
Affiliation(s)
- Katrina A. S. Davis
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, Kings College London, London, UK
| | - Cathie L. M. Sudlow
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, Kings College London, London, UK. .,Department of Psychological Medicine and SLaM/IoPPN BRC, Kings College London, PO62, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK.
| |
Collapse
|
24
|
Baltrus P, Xu J, Immergluck L, Gaglioti A, Adesokan A, Rust G. Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach. J Asthma 2016; 54:53-61. [PMID: 27285734 DOI: 10.1080/02770903.2016.1196367] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. RESULTS The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. CONCLUSIONS At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.
Collapse
Affiliation(s)
- Peter Baltrus
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,b Department of Community Health & Preventive Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Junjun Xu
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA
| | - Lilly Immergluck
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,c Departments of Microbiology , Biochemistry, & Immunology and Pediatrics, Morehouse School of Medicine , Atlanta , GA , USA
| | - Anne Gaglioti
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Adeola Adesokan
- e Master of Science in Clinical Research Program, Morehouse School of Medicine , Atlanta , GA , USA
| | - George Rust
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| |
Collapse
|
25
|
Cho J, Jung SH, Kim C, Suh M, Choi YJ, Sohn J, Cho SK, Suh I, Shin DC, Rexrode KM. Suicide loss, changes in medical care utilization, and hospitalization for cardiovascular disease and diabetes mellitus. Eur Heart J 2015; 37:764-70. [PMID: 26371117 DOI: 10.1093/eurheartj/ehv448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 08/17/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS The impact of suicide loss on family members' cardiometabolic health has little been evaluated in middle-aged and elderly people. We investigated the effect of suicide loss on risks for cardiovascular disease (CVD) and diabetes mellitus (DM) in suicide completers' family members using a national representative comparison group. METHODS AND RESULTS The study subjects were 4253 family members of suicide completers and 9467 non-bereaved family members of individuals who were age and gender matched with the suicide completers in the Republic of Korea. National health insurance data were used to identify medical care utilization during the year before and after a suicide loss. A recurrent-events survival analysis was performed to estimate the hazard ratios (HRs) of hospitalizations for CVD, DM, or psychiatric disorders, after adjusting for age, residence, and socioeconomic status. Among subjects without a past history of CVD, DM, or psychiatric disorders, the increased risks of recurrent hospitalizations were observed for CVD [HR 1.343, 95% confidence interval (CI) 1.001-1.800 in men; HR 1.240, 95% CI 1.025-1.500 in women] and DM (HR 2.238, 95% CI 1.379-3.362 in men; HR 1.786, 95% CI 1.263-2.527 in women). In subjects with a past history of CVD, DM, or psychiatric disorders, the number of medical care visits decreased after a suicide loss, and suicide completers' family members showed lower rates of hospitalization for CVD and DM than the comparison group. CONCLUSION Compared with non-bereaved family members, suicide completers' family members without a past history of CVD, DM, or psychiatric disorder showed a high risk of hospitalization for those conditions.
Collapse
Affiliation(s)
- Jaelim Cho
- Department of Occupational and Environmental Medicine, Gachon University Gil Medical Center, 774 Namdong-daero, Incheon, Republic of Korea
| | - Sang Hyuk Jung
- Department of Preventive Medicine, School of Medicine, Ewha Womans University, Anyangcheon-ro, Seoul, Republic of Korea
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Mina Suh
- National Cancer Center, 323 Ilsan-ro, Goyang, Republic of Korea
| | - Yoon Jung Choi
- Research and Development Center, Health Insurance Review and Assessment Service, 267 Hyoryung-ro, Seoul, Republic of Korea
| | - Jungwoo Sohn
- Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea
| | - Seong-Kyung Cho
- Division of Environmental Health, Korea Environment Institute, 370 Sicheong-daero, Sejong, Republic of Korea
| | - Il Suh
- Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea
| | - Dong Chun Shin
- Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seoul, Republic of Korea
| | - Kathryn M Rexrode
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| |
Collapse
|
26
|
Kurdyak P, Lin E, Green D, Vigod S. Validation of a Population-Based Algorithm to Detect Chronic Psychotic Illness. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:362-8. [PMID: 26454558 PMCID: PMC4542516 DOI: 10.1177/070674371506000805] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 01/01/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To validate algorithms to detect people with chronic psychotic illness in population-based health administrative databases. METHOD We developed 8 algorithms to detect chronic psychotic illness using hospitalization and physician service claims data from administrative health databases in Ontario to identify cases of chronic psychotic illness between 2002 and 2007. Diagnostic data abstracted from the records of 281 randomly selected psychiatric patients from 2 hospitals in Toronto were linked to the administrative data cohort to test sensitivity, specificity, and positive predictive values (PPV) and negative predictive values. RESULTS Using only hospitalization data to capture chronic psychotic illness yielded the highest specificity (range 69.9% to 84.7%) and the highest PPV (range 55.2% to 80.8%). Using physician service claims in addition to hospitalization data to capture cases increased sensitivity (range 90.1% to 98.8%) but decreased specificity (range 31.1% to 68.0%) and PPV (range 38.4% to 71.1%). CONCLUSION Using health administrative data to study population-based outcomes for people with chronic psychotic illness is feasible and valid. Researchers can select case identification methods based on whether a more sensitive or more specific definition of chronic psychotic illness is desired.
Collapse
Affiliation(s)
- Paul Kurdyak
- Director, Health Systems Research, Social and Epidemiological Research, Centre for Addiction and Mental Health, Toronto, Ontario; Lead, Mental Health and Addictions Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario; Assistant Professor, Department of Psychiatry and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Elizabeth Lin
- Research Scientist, Provincial System Support Program, Centre for Addiction and Mental Health, Toronto, Ontario; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Diane Green
- Analyst, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Simone Vigod
- Scientist, Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Assistant Professor, Department of Psychiatry and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| |
Collapse
|
27
|
Methods for identifying 30 chronic conditions: application to administrative data. BMC Med Inform Decis Mak 2015. [PMID: 25886580 DOI: 10.1186/s12911‐015‐0155‐5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity. METHODS We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year. RESULTS Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities. CONCLUSIONS We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.
Collapse
|
28
|
Tonelli M, Wiebe N, Fortin M, Guthrie B, Hemmelgarn BR, James MT, Klarenbach SW, Lewanczuk R, Manns BJ, Ronksley P, Sargious P, Straus S, Quan H. Methods for identifying 30 chronic conditions: application to administrative data. BMC Med Inform Decis Mak 2015; 15:31. [PMID: 25886580 PMCID: PMC4415341 DOI: 10.1186/s12911-015-0155-5] [Citation(s) in RCA: 270] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/02/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity. METHODS We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year. RESULTS Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities. CONCLUSIONS We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.
Collapse
Affiliation(s)
- Marcello Tonelli
- />Department of Medicine, University of Calgary, Calgary, Canada
| | - Natasha Wiebe
- />Department of Medicine, University of Alberta, Edmonton, Canada
| | - Martin Fortin
- />Department of Family Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Bruce Guthrie
- />Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | | | - Matthew T James
- />Department of Medicine, University of Calgary, Calgary, Canada
| | | | | | - Braden J Manns
- />Department of Medicine, University of Calgary, Calgary, Canada
| | - Paul Ronksley
- />Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Sharon Straus
- />Department of Medicine, University of Toronto, Toronto, Canada
| | - Hude Quan
- />Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - For the Alberta Kidney Disease Network
- />Department of Medicine, University of Calgary, Calgary, Canada
- />Department of Medicine, University of Alberta, Edmonton, Canada
- />Department of Family Medicine, Université de Sherbrooke, Sherbrooke, Canada
- />Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
- />Alberta Health Services, Edmonton, Canada
- />Department of Community Health Sciences, University of Calgary, Calgary, Canada
- />Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
29
|
Abstract
IMPORTANCE Patients with sexually transmitted infection (STI) diagnosis should be tested for human immunodeficiency virus (HIV), regardless of previous HIV test results. OBJECTIVE Estimate HIV testing rates among recent service Veterans with an STI diagnosis and variation in testing rates by patient characteristics. DESIGN, SETTING, AND PARTICIPANTS The sample comprised 243,843 Veterans who initiated Veterans Health Administration (VHA) services within 1 year after military separation. Participants were followed for 2 years to determine STI diagnoses and HIV testing rates. We used relative risks regression to examine variation in testing rates. MAIN OUTCOMES AND MEASURES We used VHA administrative data to identify STI diagnoses and HIV testing and results. RESULTS Veterans with an STI diagnosis (n = 1815) had higher HIV testing rates than those without (34.9% vs. 7.3%, P<0.0001), but were not more likely to have a positive test result (1.1% vs. 1.4%, P = 0.53). Among Veterans with an STI diagnosis, testing increased from 25% to 45% over the observation period; older age was associated with a lower rate of testing, whereas race and ethnicity, multiple deployments, posttraumatic stress disorder, and substance abuse disorders were associated with a higher rate. CONCLUSIONS AND RELEVANCE Since VHA implemented routine HIV testing, overall rates of testing have increased. However, among Veterans at significant risk for HIV because of an STI diagnosis, only 45% had an HIV test in the most recent year of observation. Other patient characteristics such as alcohol and drug abuse were associated with being tested for HIV. Providers should be reminded that an STI is a sufficient reason to test for HIV.
Collapse
|
30
|
Shimada SL, Brandt CA, Feng H, McInnes DK, Rao SR, Rothendler JA, Haggstrom DA, Abel EA, Cioffari LS, Houston TK. Personal health record reach in the Veterans Health Administration: a cross-sectional analysis. J Med Internet Res 2014; 16:e272. [PMID: 25498515 PMCID: PMC4275468 DOI: 10.2196/jmir.3751] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/17/2014] [Accepted: 11/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND My HealtheVet (MHV) is the personal health record and patient portal developed by the United States Veterans Health Administration (VA). While millions of American veterans have registered for MHV, little is known about how a patient's health status may affect adoption and use of the personal health record. OBJECTIVE Our aim was to characterize the reach of the VA personal health record by clinical condition. METHODS This was a cross-sectional analysis of all veterans nationwide with at least one inpatient admission or two outpatient visits between April 2010 and March 2012. We compared adoption (registration, authentication, opt-in to use secure messaging) and use (prescription refill and secure messaging) of MHV in April 2012 across 18 specific clinical conditions prevalent in and of high priority to the VA. We calculated predicted probabilities of adoption by condition using multivariable logistic regression models adjusting for sociodemographics, comorbidities, and clustering of patients within facilities. RESULTS Among 6,012,875 veterans, 6.20% were women, 61.45% were Caucasian, and 26.31% resided in rural areas. The mean age was 63.3 years. Nationwide, 18.64% had registered for MHV, 11.06% refilled prescriptions via MHV, and 1.91% used secure messaging with their clinical providers. Results from the multivariable regression suggest that patients with HIV, hyperlipidemia, and spinal cord injury had the highest predicted probabilities of adoption, whereas those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke had the lowest. Variation was observed across diagnoses in actual (unadjusted) adoption and use, with registration rates ranging from 29.19% of patients with traumatic brain injury to 14.18% of those with schizophrenia/schizoaffective disorder. Some of the variation in actual reach can be explained by facility-level differences in MHV adoption and by differences in patients' sociodemographic characteristics (eg, age, race, income) by diagnosis. CONCLUSIONS In this phase of early adoption, opportunities are being missed for those with specific medical conditions that require intensive treatment and self-management, which could be greatly supported by functions of a tethered personal health record.
Collapse
Affiliation(s)
- Stephanie Leah Shimada
- Center for Healthcare Organization and Implementation Research / eHealth Quality Enhancement Research Initiative, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, United States.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Daniels AM, Mandell DS. Children's compliance with American Academy of Pediatrics' well-child care visit guidelines and the early detection of autism. J Autism Dev Disord 2014; 43:2844-54. [PMID: 23619952 DOI: 10.1007/s10803-013-1831-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This study estimated compliance with American Academy of Pediatrics (AAP) guidelines for well-child care and the association between compliance and age at diagnosis in a national sample of Medicaid-enrolled children with autism (N = 1,475). Mixed effects linear regression was used to assess the relationship between compliance and age at diagnosis. Mean age at diagnosis was 37.4 (SD 8.4) months, and mean compliance was 55 % (SD 33 %). Children whose care was compliant with AAP guidelines were diagnosed 1.6 months earlier than children who received no well-child care. Findings support that the timely receipt of well-child care may contribute to earlier detection. Additional research on the contribution of compliance, well-child visit components and provider characteristics on the timely diagnosis of autism is needed.
Collapse
Affiliation(s)
- Amy M Daniels
- Autism Speaks, 1 East 33rd Street, 4th Floor, New York, NY, 10016, USA,
| | | |
Collapse
|
32
|
Katon J, Mattocks K, Zephyrin L, Reiber G, Yano EM, Callegari L, Schwarz EB, Goulet J, Shaw J, Brandt C, Haskell S. Gestational diabetes and hypertensive disorders of pregnancy among women veterans deployed in service of operations in Afghanistan and Iraq. J Womens Health (Larchmt) 2014; 23:792-800. [PMID: 25090022 DOI: 10.1089/jwh.2013.4681] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To determine the prevalence of gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) among women Veterans using Department of Veterans Affairs (VA) maternity benefits previously deployed in service of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND), and whether pregnancy complications were associated with VA use following delivery. METHODS We identified the study population through linkage with the Department of Defense roster and VA administrative and clinical data. GDM and HDP were identified by International Classification of Diseases, Ninth Revision codes in VA inpatient or outpatient files. Similarly, we constructed a nationally representative sample of deliveries from the Nationwide Inpatient Sample. We calculated standardized incidence ratios (SIR) adjusted for age and year of delivery to compare rates of GDM and HDP. Proportional hazards regression was used to determine whether pregnancy complications were associated with use of VA following delivery. RESULTS Between 2001 and 2010, 2,288 women OEF/OIF/OND Veterans used VA maternity benefits; 5.2% had GDM and 9.6% had HDP. Compared with women delivering in the United States, women OEF/OIF/OND Veterans using VA maternity benefits had higher risk of developing GDM (SIR: 1.40; 95% confidence interval [CI] 1.16, 1.68) and HDP (SIR: 1.32; 95% CI 1.15, 1.51). Among women OEF/OIF/OND Veterans using VA maternity benefits, GDM (HR 1.01, 95% CI 0.83, 1.24) and HDP (HR 1.07, 95% CI 0.92, 1.25) were not associated with use of VA following delivery. CONCLUSIONS Non-VA providers should be aware of their patients' Veteran status and the associated elevated risk for pregnancy complications. Within VA, focused efforts to optimize Veterans' preconception and postpartum health are needed.
Collapse
Affiliation(s)
- Jodie Katon
- 1 Health Services Research and Development (HSR&D) , Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Kalsekar ID, Makela EH, Moeller KE. Analysis of West Virginia medicaid claims data for the prevalence of medical conditions and use of drugs likely to cause QT prolongation in patients with schizophrenia. Curr Ther Res Clin Exp 2014; 64:538-50. [PMID: 24944403 DOI: 10.1016/j.curtheres.2003.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2003] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An important concern with antipsychotic drugs used for the treatment of schizophrenia is the prolongation of the QT interval on the electrocardiogram. Concomitant use of other QT-prolonging drugs and the presence of certain medical conditions may lead to excessive QT prolongation and subsequent cardiac arrhythmias. OBJECTIVE The aim of this study was to assess the utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation in a large population of patients with schizophrenia in practice settings. METHODS The study was conducted using West Virginia Medicaid claims data for patients aged 18 to 64 years with ≥1 medical claim for schizophrenia between January 1, 1997, and December 31, 1999. A comprehensive list of drugs and medical conditions causing QT prolongation was obtained from the literature. The drugs were identified in the prescription claims data using their specific National Drug Classification codes. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify the medical conditions as described in the medical claims files. Descriptive statistics on utilization of drugs and prevalence of medical conditions were reported and demographic differences were examined. RESULTS The final sample consisted of 1699 patients with schizophrenia. The mean (SD) age was 40.8 (11.35) years (range, 18-63 years); 55% of the patients were women. A total of 76.9% of patients utilized ≥1 nonantipsychotic QT-prolonging drug in a year, with a mean (SD) of 2.1 (1.3) such drugs used per patient per year. A total of 15.9% of patients with schizophrenia had ≥1 medical condition associated with QT prolongation. Patients with ≥1 such medical condition had a mean (SD) of 1.2 (0.57) conditions potentially causing QT prolongation. The number of nonantipsychotic QT-prolonging prescriptions filled and the prevalence of medical conditions leading to QT prolongation were found to be significantly higher for women (both P<0.001) and patients aged 34 to 64 years (both P<0.001). CONCLUSIONS In this study, a high utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation were found. These results merit assessment of predisposing risk factors, such as concurrent use of other QT-prolonging drugs and the presence of cardiovascular and other conditions associated with QT prolongation, before prescribing antipsychotics, especially in women and older patients with schizophrenia.
Collapse
Affiliation(s)
| | - Eugene H Makela
- Clinical Pharmacy, School of Pharmacy, West Virginia University, Morgantown, West Virginia, and
| | - Karen E Moeller
- Department of Pharmacy Practice, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
34
|
Higgins DM, Kerns RD, Brandt CA, Haskell SG, Bathulapalli H, Gilliam W, Goulet JL. Persistent Pain and Comorbidity Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans. PAIN MEDICINE 2014; 15:782-90. [DOI: 10.1111/pme.12388] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
35
|
Burns M, Busch A, Madden J, Le Cates RF, Zhang F, Adams A, Ross-Degnan D, Soumerai S, Huskamp H. Effects of Medicare Part D on guideline-concordant pharmacotherapy for bipolar I disorder among dual beneficiaries. Psychiatr Serv 2014; 65:323-9. [PMID: 24337444 PMCID: PMC4038978 DOI: 10.1176/appi.ps.201300123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In January 2006 insurance coverage for medications shifted from Medicaid to Medicare Part D private drug plans for the six million individuals enrolled in both programs. Dual beneficiaries faced new formularies and utilization management policies. It is unclear whether Part D, compared with Medicaid, relaxed or tightened psychiatric medication management, which could affect receipt of recommended pharmacotherapy, and emergency department use related to treatment discontinuities. This study examined the impact of the transition from Medicaid to Part D on guideline-concordant pharmacotherapy for bipolar I disorder and emergency department use. METHODS Using interrupted-time-series analysis and Medicaid and Medicare administrative data from 2004 to 2007, the authors analyzed the effect of the coverage transition on receipt of guideline-concordant antimanic medication, guideline-discordant antidepressant monotherapy, and emergency department visits for a nationally representative continuous cohort of 1,431 adults with diagnosed bipolar I disorder. RESULTS Sixteen months after the transition to Part D, the proportion of the population with any recommended use of antimanic drugs was an estimated 3.1 percentage points higher than expected once analyses controlled for baseline trends. The monthly proportion of beneficiaries with seven or more days of antidepressant monotherapy was 2.1 percentage points lower than expected. The number of emergency department visits per month temporarily increased by 19% immediately posttransition. CONCLUSIONS Increased receipt of guideline-concordant pharmacotherapy for bipolar I disorder may reflect relatively less restrictive management of antimanic medications under Part D. The clinical significance of the change is unclear, given the small effect sizes. However, increased emergency department visits merit attention for the Medicaid beneficiaries who continue to transition to Part D.
Collapse
Affiliation(s)
- Marguerite Burns
- Department of Population Health Sciences, University of Wisconsin- Madison
| | - Alisa Busch
- Department of Health Care Policy, Harvard Medical School
- McLean Hospital
| | - Jeanne Madden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Robert F. Le Cates
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | | | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Stephen Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Haiden Huskamp
- Department of Health Care Policy, Harvard Medical School
| |
Collapse
|
36
|
Shim RS, Druss BG, Zhang S, Kim G, Oderinde A, Shoyinka S, Rust G. Emergency department utilization among Medicaid beneficiaries with schizophrenia and diabetes: the consequences of increasing medical complexity. Schizophr Res 2014; 152:490-7. [PMID: 24380780 PMCID: PMC4127908 DOI: 10.1016/j.schres.2013.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 11/25/2013] [Accepted: 12/01/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity. METHODS Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes. RESULTS Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions. CONCLUSION Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones.
Collapse
Affiliation(s)
- Ruth S Shim
- National Center for Primary Care, Morehouse School of Medicine, Atlanta, GA, USA; Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta, GA, USA.
| | - Benjamin G Druss
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Shun Zhang
- National Center for Primary Care, Morehouse School of Medicine, Atlanta, GA, USA
| | - Giyeon Kim
- Center for Mental Health and Aging, The University of Alabama, Tuscaloosa, AL, USA; Department of Psychology, The University of Alabama, Tuscaloosa, AL, USA
| | - Adesoji Oderinde
- Department of Internal Medicine, Morehouse School of Medicine, USA
| | - Sosunmolu Shoyinka
- Department of Psychiatry, University of Missouri School of Medicine, USA
| | - George Rust
- National Center for Primary Care, Morehouse School of Medicine, Atlanta, GA, USA; Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| |
Collapse
|
37
|
Cidav Z, Lawer L, Marcus SC, Mandell DS. Age-related variation in health service use and associated expenditures among children with autism. J Autism Dev Disord 2013; 43:924-31. [PMID: 22941343 DOI: 10.1007/s10803-012-1637-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study examined differences by age in service use and associated expenditures during 2005 for Medicaid-enrolled children with autism spectrum disorders. Aging was associated with significantly higher use and costs for restrictive, institution-based care and lower use and costs for community-based therapeutic services. Total expenditures increased by 5 % with each year of age; by 23 % between 3-5 and 6-11 year olds, 23 % between 6-11 and 12-16, and 14 % between 12-16 and 17-20 year olds. Use of and expenditures for long-term care, psychiatric medications, case management, medication management, day treatment/partial hospitalization, and respite services increased with age; use of and expenditures for occupational/physical therapy, speech therapy, mental health services, diagnostic/assessment services, and family therapy declined.
Collapse
Affiliation(s)
- Zuleyha Cidav
- Center for Mental Health Policy & Services Research, Center for Autism Research, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | | | | | | |
Collapse
|
38
|
Stein BD, Sorbero MJ, Dalton E, Ayers AM, Farmer C, Kogan JN, Goswami U. Predictors of adequate depression treatment among Medicaid-enrolled youth. Soc Psychiatry Psychiatr Epidemiol 2013; 48:757-65. [PMID: 23589098 DOI: 10.1007/s00127-012-0593-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 09/12/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment. METHODS We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930). RESULTS Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment. CONCLUSIONS While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.
Collapse
Affiliation(s)
- Bradley D Stein
- Community Care Behavioral Health Organization, Pittsburgh, USA.
| | | | | | | | | | | | | |
Collapse
|
39
|
Marrie RA, Fisk JD, Yu BN, Leung S, Elliott L, Caetano P, Warren S, Evans C, Wolfson C, Svenson LW, Tremlett H, Blanchard JF, Patten SB. Mental comorbidity and multiple sclerosis: validating administrative data to support population-based surveillance. BMC Neurol 2013; 13:16. [PMID: 23388102 PMCID: PMC3599013 DOI: 10.1186/1471-2377-13-16] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/04/2013] [Indexed: 11/14/2022] Open
Abstract
Background While mental comorbidity is considered common in multiple sclerosis (MS), its impact is poorly defined; methods are needed to support studies of mental comorbidity. We validated and applied administrative case definitions for any mental comorbidities in MS. Methods Using administrative health data we identified persons with MS and a matched general population cohort. Administrative case definitions for any mental comorbidity, any mood disorder, depression, anxiety, bipolar disorder and schizophrenia were developed and validated against medical records using a a kappa statistic (k). Using these definitions we estimated the prevalence of these comorbidities in the study populations. Results Compared to medical records, administrative definitions showed moderate agreement for any mental comorbidity, mood disorders and depression (all k ≥ 0.49), fair agreement for anxiety (k = 0.23) and bipolar disorder (k = 0.30), and near perfect agreement for schizophrenia (k = 1.0). The age-standardized prevalence of all mental comorbidities was higher in the MS than in the general populations: depression (31.7% vs. 20.5%), anxiety (35.6% vs. 29.6%), and bipolar disorder (5.83% vs. 3.45%), except for schizophrenia (0.93% vs. 0.93%). Conclusions Administrative data are a valid means of surveillance of mental comorbidity in MS. The prevalence of mental comorbidities, except schizophrenia, is increased in MS compared to the general population.
Collapse
Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Krupski A, Sears JM, Joesch JM, Estee S, He L, Huber A, Dunn C, Roy-Byrne P, Ries R. Self-reported alcohol and drug use six months after brief intervention: do changes in reported use vary by mental-health status? Addict Sci Clin Pract 2012. [PMID: 23186062 PMCID: PMC3685518 DOI: 10.1186/1940-0640-7-24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Although brief intervention (BI) for alcohol and other drug problems has been associated with subsequent decreased levels of self-reported substance use, there is little information in the extant literature as to whether individuals with co-occurring hazardous substance use and mental illness would benefit from BI to the same extent as those without mental illness. This is an important question, as mental illness is estimated to co-occur in 37% of individuals with an alcohol use disorder and in more than 50% of individuals with a drug use disorder. The goal of this study was to explore differences in self-reported alcohol and/or drug use in patients with and without mental illness diagnoses six months after receiving BI in a hospital emergency department (ED). Methods This study took advantage of a naturalistic situation where a screening, brief intervention, and referral to treatment (SBIRT) program had been implemented in nine large EDs in the US state of Washington as part of a national SBIRT initiative. A subset of patients who received BI was interviewed six months later about current alcohol and drug use. Linear regression was used to assess whether change in substance use measures differed among patients with a mental illness diagnosis compared with those without. Data were analyzed for both a statewide (n = 828) and single-hospital (n = 536) sample. Results No significant differences were found between mentally ill and non-mentally ill subgroups in either sample with regard to self-reported hazardous substance use at six-month follow-up. Conclusion These results suggest that BI may not have a differing impact based on the presence of a mental illness diagnosis. Given the high prevalence of mental illness among individuals with alcohol and other drug problems, this finding may have important public health implications.
Collapse
Affiliation(s)
- Antoinette Krupski
- Department of Psychiatry and Behavioral Sciences, Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP), University of Washington at Harborview Medical Center, Seattle, WA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Farley JF, Hansen RA, Yu-Isenberg KS, Maciejewski ML. Antipsychotic adherence and its correlation to health outcomes for chronic comorbid conditions. Prim Care Companion CNS Disord 2012; 14:11m01324. [PMID: 23106028 DOI: 10.4088/pcc.11m01324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 02/09/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To examine the relationship between adherence to antipsychotics and adherence to medications for cardiometabolic conditions (diabetes, hypertension, and hyperlipidemia) and subsequent health care utilization and expenditures in patients with schizophrenia and preexisting cardiometabolic conditions. METHOD Medstat MarketScan Medicaid databases from 2004 to 2008 were used to identify a retrospective cohort of schizophrenia patients (ICD-9-CM codes 295.1-295.3, 295.6, or 295.9) with preexisting cardiometabolic medication use who had initiated antipsychotic treatments. Patients who initiated a second-generation antipsychotic between July 1, 2004, and December 31, 2006, were identified as the new user cohort. Comorbid conditions were identified if patients had at least 1 inpatient or 2 outpatient claims for hypertension, hyperlipidemia, and/or diabetes (ICD-9-CM codes 401.xx to 405.xx inclusive, 272.xx inclusive, and 250.xx inclusive, respectively) and were using medication to manage these conditions prior to antipsychotic initiation. Adherence to cardiometabolic medications was compared between adherent and nonadherent patients taking antipsychotics using the proportion of days covered over 8 quarters categorized as phases of treatment to reflect initiation (1, days 1-90), continuation (2-4, days 91-360), and maintenance (5-8, days 361-520). Proportion of days covered values ≥ 0.80 were deemed adherent. Prior period antipsychotic adherence was used to predict cardiometabolic medication adherence, health care utilization, and expenditures using generalized estimating equations and negative binomial regressions. RESULTS The final population represented 1,006 patients. Antipsychotic adherence during continuation was a significant predictor of medication adherence for hypertension (odds ratio [OR] = 2.40, 95% CI = 1.67-3.44), diabetes (OR = 2.28, 95% CI = 1.43-3.67), and hyperlipidemia (OR = 2.16, 95% CI = 1.11-4.20) during maintenance. Antipsychotic adherence during continuation resulted in significantly lower emergency room use (OR = 0.67, 95% CI = 0.52-0.87), lower inpatient use (OR = 0.77, 95% CI = 0.56-1.06, not significant), and significantly higher outpatient ($996, 95% CI = $663-$1,330), medication ($652, 95% CI = $542-$762), and total health ($1,371, 95% CI = $490-$2,252) expenditures during maintenance. CONCLUSION Antipsychotic adherence was associated with better adherence to cardiometabolic medications and a potential reduction in emergency room and inpatient service utilization. Clinicians should consider adherence to both antipsychotic and cardiometabolic medications when caring for patients with schizophrenia and comorbid conditions.
Collapse
Affiliation(s)
- Joel F Farley
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill (Dr Farley); Harrison School of Pharmacy, Auburn University, Auburn, Alabama (Dr Hansen); Global Health Economics and Outcomes Research, GlaxoSmithKline, Durham, North Carolina (Dr Yu-Isenberg); and Division of General Internal Medicine, Durham VA Medical Center and Duke University, Durham, North Carolina (Dr Maciejewski)
| | | | | | | |
Collapse
|
42
|
Olfson M, Gerhard T, Huang C, Lieberman JA, Bobo WV, Crystal S. Comparative effectiveness of second-generation antipsychotic medications in early-onset schizophrenia. Schizophr Bull 2012; 38:845-53. [PMID: 21307041 PMCID: PMC3406514 DOI: 10.1093/schbul/sbq172] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2010] [Indexed: 11/14/2022]
Abstract
Scant information exists to guide pharmacological treatment of early-onset schizophrenia. We examine variation across commonly prescribed second-generation antipsychotic medications in medication discontinuation and psychiatric hospital admission among children and adolescents clinically diagnosed with schizophrenia. A 45-state Medicaid claims file (2001-2005) was analyzed focusing on outpatients, aged 6-17 years, diagnosed with schizophrenia or a related disorder prior to starting a new episode of antipsychotic monotherapy with risperidone (n = 805), olanzapine (n = 382), quetiapine (n = 260), aripiprazole (n = 173), or ziprasidone (n = 125). Cox proportional hazard regressions estimated adjusted hazard ratios of 180-day antipsychotic medication discontinuation and 180-day psychiatric hospitalization for patients treated with each medication. During the first 180 days following antipsychotic initiation, most youth treated with quetiapine (70.7%), ziprasidone (73.3%), olanzapine (73.7%), risperidone (74.7%), and aripirazole (76.5%) discontinued their medication (χ(2) = 1.69, df = 4, P = .79). Compared with risperidone, the adjusted hazards of antipsychotic discontinuation did not significantly differ for any of the 4-comparator medications. The percentages of youth receiving inpatient psychiatric treatment while receiving their initial antipsychotic medication ranged from 7.19% (aripiprazole) to 9.89% (quetiapine) (χ(2) = 0.79, df = 4, P = .94). As compared with risperidone, the adjusted hazard ratio of psychiatric hospital admission was 0.96 (95% CI: 0.57-1.61) for olanzapine, 1.03 (95% CI: 0.59-1.81) for quetiapine, 0.85 (95% CI: 0.43-1.70) for aripiprazole, and 1.22 (95% CI: 0.60-2.51) for ziprasidone. The results suggest that rapid antipsychotic medication discontinuation and psychiatric hospital admission are common in the community treatment of early-onset schizophrenia. No significant differences were detected in risk of either adverse outcome across 5 commonly prescribed second-generation antipsychotic medications.
Collapse
Affiliation(s)
- Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | | | | | | | | | | |
Collapse
|
43
|
Duffy SA, Kilbourne AM, Austin KL, Dalack GW, Woltmann EM, Waxmonsky JA, Noonan D. Risk of smoking and receipt of cessation services among veterans with mental disorders. Psychiatr Serv 2012; 63:325-32. [PMID: 22337005 PMCID: PMC3323716 DOI: 10.1176/appi.ps.201100097] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to determine rates of smoking and receipt of provider recommendations to quit smoking among patients with mental disorders treated in U.S. Department of Veterans Affairs (VA) treatment settings. METHODS The authors conducted a secondary analysis of the yearly, cross-sectional 2007 Veterans Health Administration Outpatient Survey of Healthcare Experiences of Patients (N=224,193). Logistic regression was used to determine the independent association of mental health diagnosis and the dependent variables of smoking and receipt of provider recommendations to quit smoking. RESULTS Patients with mental disorders had greater odds of smoking, compared with those without mental disorders (p<.05). Those with various mental disorders reported similar rates of receiving services (more than 60% to 80% reported receiving selected services), compared with those without these disorders, except that those with schizophrenia had more than 30% lower odds of receiving advice to quit smoking from their physicians (p<.05). Moreover, those who had co-occurring posttraumatic stress disorder or substance use disorders had significantly greater odds of reporting that they received advice to quit, recommendations for medications, and physician discussions of quitting methods, compared with those without these disorders (p<.05). Older patients, male patients, members of ethnic minority groups, those who were unmarried, those who were disabled or unemployed, and those living in rural areas had lower odds of receiving selected services (p<.05). CONCLUSIONS The majority of patients with mental disorders served by the VA reported receiving cessation services, yet their smoking rates remained high, and selected groups were at risk for receiving fewer cessation services, suggesting the continued need to disseminate cessation services.
Collapse
Affiliation(s)
- Sonia A. Duffy
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Amy M. Kilbourne
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Karen L. Austin
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Gregory W. Dalack
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Emily M. Woltmann
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Jeanette A. Waxmonsky
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| | - Devon Noonan
- Dr. Duffy, Dr. Kilbourne, Ms. Austin, and Dr. Woltmann are affiliated with the VA Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center 2215 Fuller Rd., Ann Arbor, MI 48105 (). Dr. Duffy, Dr. Kilbourne, and Dr. Dalack are with the Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr. Duffy is with the Department of Otolaryngology, University of Michigan, Ann Arbor, MI. Dr. Waxmonsky is with the Depression Center and the Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO. Dr. Duffy and Dr. Noonan are with the School of Nursing, University of Michigan, Ann Arbor, MI
| |
Collapse
|
44
|
Medicare part D's impact on antipsychotic drug use and costs among elderly patients without prior drug insurance. J Clin Psychopharmacol 2012; 32:3-10. [PMID: 22198455 PMCID: PMC3419531 DOI: 10.1097/jcp.0b013e31823fb5c4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Medicare part D's implementation improved access to and affordability of prescription drugs for the elderly without prior drug insurance. Effects for specific drugs and drug classes are less well understood. We assessed part D's impact on antipsychotic medication (APM) utilization and out-of-pocket costs among elderly without prior drug insurance. Retail pharmacy claims from 3 nationwide pharmacy chains were used to analyze 2 time-series designs: (1) a policy model, to obtain a policymaker's perspective: what was the overall impact of part D on APM use and costs among elderly without drug insurance in 2005 with the opportunity to enroll? And (2) a clinical model, to obtain a clinician's perspective: what would happen to elderly without drug insurance in 2005 who did enroll in part D--would they be able to get APMs? At what cost? Subgroup analyses among part D enrollees evaluated potentially different effects for patients who received a subsidy and patients who used antidementia drugs. In the policy model, part D implementation was associated with a 5% increase in APM use and a 37% reduction in out-of-pocket costs, suggesting a modest need for APMs among all previously uninsured elderly. Patients who did enroll in part D (clinical model) had a 97% increase in APM use and a 62% decrease in out-of-pocket costs, suggesting that patients who needed APMs were able to access them at low cost through the part D program. Part D implementation was associated with increased use and affordability of APMs for the elderly without prior drug insurance.
Collapse
|
45
|
Kim HM, Smith EG, Stano CM, Ganoczy D, Zivin K, Walters H, Valenstein M. Validation of key behaviourally based mental health diagnoses in administrative data: suicide attempt, alcohol abuse, illicit drug abuse and tobacco use. BMC Health Serv Res 2012; 12:18. [PMID: 22270080 PMCID: PMC3280157 DOI: 10.1186/1472-6963-12-18] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 01/23/2012] [Indexed: 11/16/2022] Open
Abstract
Background Observational research frequently uses administrative codes for mental health or substance use diagnoses and for important behaviours such as suicide attempts. We sought to validate codes (International Classification of Diseases, 9th edition, clinical modification diagnostic and E-codes) entered in Veterans Health Administration administrative data for patients with depression versus a gold standard of electronic medical record text ("chart notation"). Methods Three random samples of patients were selected, each stratified by geographic region, gender, and year of cohort entry, from a VHA depression treatment cohort from April 1, 1999 to September 30, 2004. The first sample was selected from patients who died by suicide, the second from patients who remained alive on the date of death of suicide cases, and the third from patients with a new start of a commonly used antidepressant medication. Four variables were assessed using administrative codes in the year prior to the index date: suicide attempt, alcohol abuse/dependence, drug abuse/dependence and tobacco use. Results Specificity was high (≥ 90%) for all four administrative codes, regardless of the sample. Sensitivity was ≤75% and was particularly low for suicide attempt (≤ 17%). Positive predictive values for alcohol dependence/abuse and tobacco use were high, but barely better than flipping a coin for illicit drug abuse/dependence. Sensitivity differed across the three samples, but was highest in the suicide death sample. Conclusions Administrative data-based diagnoses among VHA records have high specificity, but low sensitivity. The accuracy level varies by different diagnosis and by different patient subgroup.
Collapse
Affiliation(s)
- Hyungjin Myra Kim
- Center for Statistical Consultation and Research, 3555 Rackham, University of Michigan, Ann Arbor, MI 48109-1070, USA.
| | | | | | | | | | | | | |
Collapse
|
46
|
dosReis S, Yoon Y, Rubin DM, Riddle MA, Noll E, Rothbard A. Antipsychotic treatment among youth in foster care. Pediatrics 2011; 128:e1459-66. [PMID: 22106072 PMCID: PMC3387900 DOI: 10.1542/peds.2010-2970] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Despite national concerns over high rates of antipsychotic medication use among youth in foster care, concomitant antipsychotic use has not been examined. In this study, concomitant antipsychotic use among Medicaid-enrolled youth in foster care was compared with disabled or low-income Medicaid-enrolled youth. PATIENTS AND METHODS The sample included 16 969 youths younger than 20 years who were continuously enrolled in a Mid-Atlantic state Medicaid program and had ≥1 claim with a psychiatric diagnosis and ≥1 antipsychotic claim in 2003. Antipsychotic treatment was characterized by days of any use and concomitant use with ≥2 overlapping antipsychotics for >30 days. Medicaid program categories were foster care, disabled (Supplemental Security Income), and Temporary Assistance for Needy Families (TANF). Multicategory involvement for youths in foster care was classified as foster care/Supplemental Security Income, foster care/TANF, and foster care/adoption. We used multivariate analyses, adjusting for demographics, psychiatric comorbidities, and other psychotropic use, to assess associations between Medicaid program category and concomitant antipsychotic use. RESULTS Average antipsychotic use ranged from 222 ± 110 days in foster care to only 135 ± 101 days in TANF (P < .001). Concomitant use for ≥180 days was 19% in foster care only and 24% in foster care/adoption compared with <15% in the other categories. Conduct disorder and antidepressant or mood-stabilizer use was associated with a higher likelihood of concomitant antipsychotic use (P < .0001). CONCLUSIONS Additional study is needed to assess the clinical rationale, safety, and outcomes of concomitant antipsychotic use and to inform statewide policies for monitoring and oversight of antipsychotic use among youths in the foster care system.
Collapse
Affiliation(s)
- Susan dosReis
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Yesel Yoon
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David M. Rubin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and
| | - Mark A. Riddle
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth Noll
- Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aileen Rothbard
- Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
47
|
Walkup J, Akincigil A, Hoover DR, Siegel MJ, Amin S, Crystal S. Use of Medicaid data to explore community characteristics associated with HIV prevalence among beneficiaries with schizophrenia. Public Health Rep 2011; 126 Suppl 3:89-101. [PMID: 21836742 DOI: 10.1177/00333549111260s314] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES People with severe mental illness (SMI) may be at increased risk for several adverse health conditions, including HIV/AIDS. This disproportionate disease burden has been studied primarily at the individual rather than community level, in part due to the rarity of data sources linking individual information on medical and mental health characteristics with community-level data. We demonstrated the potential of Medicaid data to address this gap. METHODS We analyzed data on Medicaid beneficiaries with schizophrenia from eight states that account for 66% of cumulative AIDS cases nationally. RESULTS Across 44 metropolitan statistical areas (MSAs), the treated prevalence of HIV among adult Medicaid beneficiaries diagnosed with schizophrenia was 1.56% (standard deviation = 1.31%). To explore possible causes of variation, we linked claims files with a range of MSA social and contextual variables including local AIDS prevalence rates, area-based economic measures, crime rates, substance abuse treatment resources, and estimates of injection drug users (IDUs) and HIV infection among IDUs, which strongly predicted community infection rates among people with schizophrenia. CONCLUSIONS Effective strategies for HIV prevention among people with SMI may include targeting prevention efforts to areas where risk is greatest; examining social network links between IDU and SMI groups; and implementing harm reduction, drug treatment, and other interventions to reduce HIV spread among IDUs. Our findings also suggest the need for research on HIV among people with SMI that examines geographical variation and demonstrates the potential use of health-care claims data to provide epidemiologic insights into small-area variations and trends in physical health among those with SMI.
Collapse
Affiliation(s)
- James Walkup
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Lo Re V, Lim JK, Goetz MB, Tate J, Bathulapalli H, Klein MB, Rimland D, Rodriguez-Barradas MC, Butt AA, Gibert CL, Brown ST, Kidwai F, Brandt C, Dorey-Stein Z, Reddy KR, Justice AC. Validity of diagnostic codes and liver-related laboratory abnormalities to identify hepatic decompensation events in the Veterans Aging Cohort Study. Pharmacoepidemiol Drug Saf 2011; 20:689-99. [PMID: 21626605 DOI: 10.1002/pds.2148] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 03/21/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE The absence of validated methods to identify hepatic decompensation in cohort studies has prevented a full understanding of the natural history of chronic liver diseases and impact of medications on this outcome. We determined the ability of diagnostic codes and liver-related laboratory abnormalities to identify hepatic decompensation events within the Veterans Aging Cohort Study (VACS). METHODS Medical records of patients with hepatic decompensation codes and/or laboratory abnormalities of liver dysfunction (total bilirubin ≥ 5.0 g/dL, albumin ≤ 2.0 g/dL, INR ≥ 1.7) recorded 1 year before through 6 months after VACS entry were reviewed to identify decompensation events (i.e., ascites, spontaneous bacterial peritonitis, variceal hemorrhage, hepatic encephalopathy, hepatocellular carcinoma) at VACS enrollment. Positive predictive values (PPVs) of diagnostic codes, laboratory abnormalities, and their combinations for confirmed outcomes were determined. RESULTS Among 137 patients with a hepatic decompensation code and 197 with a laboratory abnormality, the diagnosis was confirmed in 57 (PPV, 42%; 95%CI, 33%-50%) and 56 (PPV, 28%; 95%CI, 22%-35%) patients, respectively. The combination of any code plus laboratory abnormality increased PPV (64%; 95%CI, 47%-79%). One inpatient or ≥2 outpatient diagnostic codes for ascites, spontaneous bacterial peritonitis, or variceal hemorrhage had high PPV (91%; 95%CI, 77%-98%) for confirmed hepatic decompensation events. CONCLUSION An algorithm of 1 inpatient or ≥ 2 outpatient codes for ascites, peritonitis, or variceal hemorrhage has sufficiently high PPV for hepatic decompensation to enable its use for epidemiologic research in VACS. This algorithm may be applicable to other cohorts.
Collapse
Affiliation(s)
- Vincent Lo Re
- Philadelphia VA Medical Center, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Salyers MP, Rollins AL, Clendenning D, McGuire AB, Kim E. Impact of illness management and recovery programs on hospital and emergency room use by Medicaid enrollees. Psychiatr Serv 2011; 62:509-15. [PMID: 21532077 PMCID: PMC3093966 DOI: 10.1176/ps.62.5.pss6205_0509] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Illness management and recovery is a structured program that helps consumers with severe mental illness learn effective ways to manage illness and pursue recovery goals. This study examined the impact of the program on health service utilization. METHODS This was a retrospective cohort study of five assertive community treatment (ACT) teams in Indiana that implemented illness management and recovery. With Medicaid claims data from July 1, 2003, to June 30, 2008, panel data were created with person-months as the level of analysis, resulting in 14,261 observations for a total of 498 unique individuals. Zero-inflated negative binomial regression models were used to predict hospitalization days and emergency room visits, including covariates of demographic characteristics, employment status, psychiatric diagnosis, and concurrent substance use disorder. The main predictor variables of interest were receipt of illness management and recovery services, dropout from the program, and program graduation status. RESULTS Consumers who received some illness management and recovery services had fewer hospitalization days than those receiving only ACT. Graduates had fewer emergency room visits than did ACT-only consumers. CONCLUSIONS This is the first study to examine the impact of illness management and recovery on service utilization. Controlling for a number of background variables, the study showed that illness management and recovery programs were associated with reduced inpatient hospitalization and emergency room use over and above ACT.
Collapse
Affiliation(s)
- Michelle P Salyers
- Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, IN 46202, USA.
| | | | | | | | | |
Collapse
|
50
|
Haskell SG, Mattocks K, Goulet JL, Krebs EE, Skanderson M, Leslie D, Justice AC, Yano EM, Brandt C. The burden of illness in the first year home: do male and female VA users differ in health conditions and healthcare utilization. Womens Health Issues 2011; 21:92-7. [PMID: 21185994 PMCID: PMC3138124 DOI: 10.1016/j.whi.2010.08.001] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND we sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan. METHODS this is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment. RESULTS female veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders. CONCLUSION female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive women's health services within the VA.
Collapse
Affiliation(s)
- Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|