Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care

OBJECTIVE

Recent policy has focused on documenting and reducing ethnic disparities in availability and quality of health care. The authors examined differences by ethnic status in unmet need for alcoholism, drug abuse, and mental health treatment.

METHOD

Data were from a follow-up survey of adult respondents to a 1996-1997 national survey. Non-Hispanic whites, African Americans, and Hispanics were compared in access to alcoholism and drug abuse treatment and mental health care (primary or specialty), unmet need for care, satisfaction with care, and use of active treatment for alcoholism, drug abuse, and mental health problems in the prior 12 months.

RESULTS

A total of 31.9% of whites, 28.1% of African Americans, and 30.1% of Hispanics had some alcoholism, drug abuse, and mental health care, mostly in primary care. Among those with perceived need, compared to whites, African Americans were more likely to have no access to alcoholism, drug abuse, or mental health care (25.4% versus 12.5%), and Hispanics were more likely to have less care than needed or delayed care (22.7% versus 10.7%). Among those with need, whites were more likely than Hispanics or African Americans to be receiving active alcoholism, drug abuse, or mental health treatment (37.6% versus 22.4%-25.0%).

CONCLUSIONS

The authors document greater unmet need for alcoholism and drug abuse treatment and mental health care among African American and Hispanics relative to whites. New policies are needed to improve access to and quality of alcoholism, drug abuse, and mental health treatment across diverse populations.

Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial

CONTEXT

Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.

OBJECTIVE

To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.

DESIGN

Group-level randomized controlled trial conducted June 1996 to July 1999.

SETTING

Forty-six primary care clinics in 6 community-based managed care organizations.

PARTICIPANTS

One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.

INTERVENTIONS

Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.

MAIN OUTCOME MEASURES

Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.

RESULTS

Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.

CONCLUSIONS

Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

Can quality improvement programs for depression in primary care address patient preferences for treatment?

BACKGROUND

Depression is common in primary care, but rates of adequate care are low. Little is known about the role of patient treatment preferences in encouraging entry into care.

OBJECTIVES

To examine whether a primary care based depression quality improvement (QI) intervention designed to accommodate patient and provider treatment choice increases the likelihood that patients enter depression treatment and receive preferred treatment.

METHODS

In 46 primary care clinics, patients with current depressive symptoms and either lifetime or current depressive disorder were identified through screening. Treatment preferences, patient characteristics, and use of depression treatments were assessed at baseline and 6 months by patient self-report. Matched clinics were randomized to usual care (UC) or 1 of 2 QI interventions. Data were analyzed using logistic regression models.

RESULTS

For patients not in care at baseline, the QI interventions increased rates of entry into depression treatment compared with usual care (adjusted percentage: 50.0% +/- 5.3 and 33.0% +/- 4.9 for interventions vs. 15.9% +/- 3.6 for usual care; F = 12.973, P <0.0001). Patients in intervention clinics were more likely to get treatments they preferred compared with those in usual care (adjusted percentage: 54.2% +/- 3.3 and 50.7% +/- 3.1 for interventions vs. 40.5% +/- 3.1 for usual care; F = 6.034, P <0.003); however, in all clinics less than half of patients preferring counseling reported receiving it.

CONCLUSIONS

QI interventions that support patient choice can improve the likelihood of patients receiving preferred treatments. Patient treatment preference appears to be related to likelihood of entering depression treatment, and patients preferring counseling may require additional interventions to enhance entry into treatment.

Use of mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND

The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care.

METHODS

Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use.

RESULTS

We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services.

CONCLUSIONS

The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.

An English and Spanish Pediatric Asthma Symptom Scale

BACKGROUND

Pediatric asthma survey measures have not been adequately tested in non-English-speaking populations.

OBJECTIVES

To test the reliability and validity of an English and Spanish symptom scale to measure asthma control in children.

SUBJECTS

Parents (54% Spanish-speaking; 61% not high school graduates) of 234 children seen in the emergency department for an asthma exacerbation.

MEASURES

Parent report of frequency and perceived severity of child asthma symptoms during the beginning and after resolution of the exacerbation.

RESULTS

An 8-item scale composed of reports of cough, wheezing, shortness of breath, asthma attacks, chest pain, night symptoms, and overall perceived severity had very good psychometric properties in both English and Spanish. The reliability (Cronbach's alpha) of the scale ranged from 0.81 to 0.87 for both languages and time frames. In both languages, the validity of the scale was supported by responsiveness to changes in clinical status (lower symptom score after resolution of the exacerbation, P < 0.001) and by moderate to strong correlations (P < 0.001) with other asthma morbidity measures (parent report of child bother: r = 0.59-0.65; school days lost: r = 0.38-0.67; and activity days lost: r = 0.41-0.59). There were no statistically significant differences in the reliability or construct validity of the summary symptom scale by language, although Spanish speakers reported a lower frequency of some symptoms than did English speakers.

CONCLUSIONS

A reliable and valid 8-item scale can be used to measure control of asthma symptoms in Spanish-speaking populations of low literacy. Additional research to evaluate language equivalency of asthma measures is necessary.

Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial

CONTEXT

Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.

OBJECTIVE

To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.

DESIGN

Randomized controlled trial initiated from June 1996 to March 1997.

SETTING

Forty-six primary care clinics in 6 US managed care organizations.

PARTICIPANTS

Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.

INTERVENTIONS

Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.

MAIN OUTCOME MEASURES

Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.

RESULTS

Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).

CONCLUSIONS

When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

The design of Healthcare for Communities: a study of health care delivery for alcohol, drug abuse, and mental health conditions

There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

Differences between child and parent reports of symptoms among Latino children with asthma

OBJECTIVES

To determine, in a population of predominantly Latino children with asthma 6 to 18 years old, whether parent and child reports of asthma symptoms with exercise differ and to evaluate the validity of child and parent reports of symptoms.

DESIGN

Data obtained from child and parent interviews; pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow25-75, peak expiratory flow), and observation of symptoms after exercise.

SETTING

Three summer camps for minority children with asthma in Los Angeles County.

PARTICIPANTS

A total of 97 children with asthma (78% Latino, 12% non-Latino White, 9% Other; 6 to 18 years of age) and their parents.

INTERVENTION(S)

None.

PRIMARY OUTCOME MEASURES

Child and parent reports of cough and wheezing with exercise and pulmonary function tests before and after exercise. While at camp, children underwent spirometry after completing the self-administered survey. The pulmonary function tests were conducted and interpreted according to the pediatric specifications for spirometry, and results >80% of predicted, adjusted for gender, age, height, and race, were considered normal. Six peak expiratory flow rates (PEFR) by peak flow meter also were recorded by trained research assistants immediately before spirometry, and values >80% of predicted based on height were considered normal. To observe child symptoms with exercise, children participated in a relay running race of 200 feet followed by a swimming race of 300 feet. Research assistants measured heart rate and 6 PEFRs using ASSESS portable peak flow meters immediately before and after each exercise. A positive exercise challenge was defined as a 15% reduction in mean PEFR and/or observed asthma symptoms (cough, wheezing, chest pain, asthma attack).

RESULTS

Of the children, 18% reported never having a cough when they exercised, 46% reported having it occasionally when they exercised, and 36% reported having it quite often or always when they exercised. For wheezing, 20% of children reported never having wheezing when they exercised, 35% having it occasionally when they exercised, and 45% having it quite often or always when they exercised. Parents reported fewer symptoms than did their children. Of the parents, 34% reported that their children did not have cough with exercise, 37% reported few to some days, and 29% reported most days or every day. Forty-seven percent of parents reported that their child did not wheeze with exercise in the last 2 months, 35% reported wheezing on a few days to some days, and 17% reported wheezing most days to every day. Parent and child reports of cough or wheezing after exercise correlated mildly with each other (parent/child cough r = 0. 23; kappa = 0.03; parent/child wheezing r = 0.21; kappa = 0.14). Children were more likely to report cough: 59 of 71 (83%) of children versus 44 of 71 (62%) of parents. The 22 children who reported cough when their parents did not account for most of the disagreement between parents and children. Children were more likely than were their parents to report wheezing; 55 of 69 (80%) children versus 36 of 69 (52%) parents reported that the child wheezed. The 24 children who reported wheezing when their parents did not account for most of the disagreement between parents and children. Forty-seven percent of the children had a value <80% of predicted for at least one of the four spirometry tests; 29% of mean baseline PEFRs were <80% of predicted. Overall, 86% of the children met one or more of the following: any percent of predicted pulmonary function tests <80% or any symptom or PEFR reduction of 15% after exercise, or other occurrence of nonexercise symptoms during camp. Almost all child reports of cough and wheezing correlated significantly with the criterion validity criteria. For example, child reports of wheezing were, as expected, correlated negatively with the percent of predicted FEV1 (r = -0.28) and correlated positive

Access to infant immunizations for poor, inner-city families: what is the impact of managed care?

California plans to enroll half of its Medicaid population, 75 percent of which are children, into managed care. To measure the impact of managed care on utilization of preventive services, we surveyed 867 families in two inner-city areas of Los Angeles and assessed the relationship between insurance type, source of care, and access to immunization services. Compared to children in public health clinics, those in private physicians' offices or health maintenance organizations (HMOs) had odds of being up-to-date on immunizations of 0.43 (p < .01) and 0.24 (p < .01), respectively. We conclude that in the absence of meaningful financial incentives to encourage private physicians and HMOs to provide immunizations to inner-city children, managed care is unlikely to improve immunization rates among this vulnerable population.