Emergency Department Length of Stay for Older Adults With Dementia

STUDY OBJECTIVE

The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile).

METHODS

In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay.

RESULTS

We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4).

CONCLUSION

ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.

Cost-Effectiveness of Gene-Specific Prevention Strategies for Ovarian and Breast Cancer

Importance

Pathogenic variants (PVs) in BRCA1, BRCA2, PALB2, RAD51C, RAD51D, and BRIP1 cancer susceptibility genes (CSGs) confer an increased ovarian cancer (OC) risk, with BRCA1, BRCA2, PALB2, RAD51C, and RAD51D PVs also conferring an elevated breast cancer (BC) risk. Risk-reducing surgery, medical prevention, and BC surveillance offer the opportunity to prevent cancers and deaths, but their cost-effectiveness for individual CSGs remains poorly addressed.

Objective

To estimate the cost-effectiveness of prevention strategies for OC and BC among individuals carrying PVs in the previously listed CSGs.

Design, Setting, and Participants

In this economic evaluation, a decision-analytic Markov model evaluated the cost-effectiveness of risk-reducing salpingo-oophorectomy (RRSO) and, where relevant, risk-reducing mastectomy (RRM) compared with nonsurgical interventions (including BC surveillance and medical prevention for increased BC risk) from December 1, 2022, to August 31, 2023. The analysis took a UK payer perspective with a lifetime horizon. The simulated cohort consisted of women aged 30 years who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. Appropriate sensitivity and scenario analyses were performed.

Exposures

CSG-specific interventions, including RRSO at age 35 to 50 years with or without BC surveillance and medical prevention (ie, tamoxifen or anastrozole) from age 30 or 40 years, RRM at age 30 to 40 years, both RRSO and RRM, BC surveillance and medical prevention, or no intervention.

Main Outcomes and Measures

The incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained. OC and BC cases and deaths were estimated.

Results

In the simulated cohort of women aged 30 years with no cancer, undergoing both RRSO and RRM was most cost-effective for individuals carrying BRCA1 (RRM at age 30 years; RRSO at age 35 years), BRCA2 (RRM at age 35 years; RRSO at age 40 years), and PALB2 (RRM at age 40 years; RRSO at age 45 years) PVs. The corresponding ICERs were -£1942/QALY (-$2680/QALY), -£89/QALY (-$123/QALY), and £2381/QALY ($3286/QALY), respectively. RRSO at age 45 years was cost-effective for RAD51C, RAD51D, and BRIP1 PV carriers compared with nonsurgical strategies. The corresponding ICERs were £962/QALY ($1328/QALY), £771/QALY ($1064/QALY), and £2355/QALY ($3250/QALY), respectively. The most cost-effective preventive strategy per 1000 PV carriers could prevent 923 OC and BC cases and 302 deaths among those carrying BRCA1; 686 OC and BC cases and 170 deaths for BRCA2; 464 OC and BC cases and 130 deaths for PALB2; 102 OC cases and 64 deaths for RAD51C; 118 OC cases and 76 deaths for RAD51D; and 55 OC cases and 37 deaths for BRIP1. Probabilistic sensitivity analysis indicated both RRSO and RRM were most cost-effective in 96.5%, 89.2%, and 84.8% of simulations for BRCA1, BRCA2, and PALB2 PVs, respectively, while RRSO was cost-effective in approximately 100% of simulations for RAD51C, RAD51D, and BRIP1 PVs.

Conclusions and Relevance

In this cost-effectiveness study, RRSO with or without RRM at varying optimal ages was cost-effective compared with nonsurgical strategies for individuals who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. These findings support personalizing risk-reducing surgery and guideline recommendations for individual CSG-specific OC and BC risk management.

The impact of full practice authority on nurse practitioner compensation, collaboration, and billing

BACKGROUND

Although there is a substantial body of evidence regarding full practice authority's (FPA) effects on health care access and quality, very little research has examined how nurse practitioner (NP) licensure laws affect the status of NPs as clinicians, employees, and leaders in health care organizations.

PURPOSE

This study examined whether states' implementation of FPA leads to higher pay, business ownership, assigned patient panel, and billing transparency for NPs' and whether NPs' gains from FPA increase over time in states where FPA has been in effect longer.

METHODOLOGY

Data from a nationwide survey of licensed NPs ( N = 5,770) were used to compare NPs' employment conditions between FPA and non-FPA states. After balancing the FPA and non-FPA groups on demographic characteristics (e.g., urbanicity, education), adjusted mean differences in outcomes between the groups were estimated using weighted multivariable regression.

RESULTS

Compared with NPs in non-FPA states, NPs in FPA states had higher mean earnings ( p < .05), were more likely to be practice owners or shareholders ( p < .01), and billed a greater percentage of their patient visits under their own National Provider Identifier ( p < .001). Having FPA in place for ≥10 years was associated with greater improvements in conditions of employment compared with having FPA <10 years.

CONCLUSIONS

States' adoption of FPA for NPs is associated with improved conditions of employment among NPs.

IMPLICATIONS

Untethering NPs from physicians establishes a cascade of modest gains in income and practice ownership that may indicate changes over time. Additional research is needed to determine the trajectory of these increases and if they are consistent.

Cost-Effectiveness Analysis of School-Based Treatments for Anxiety Disorders

BACKGROUND

School-based treatments for anxiety disorders are needed to address barriers to accessing community-based services. A key question for school administers are the costs related to these treatments.

AIMS OF THE STUDY

This study examined the cost-effectiveness of a school-based modular cognitive behavioral therapy (M-CBT) for pediatric anxiety disorders compared to school-based treatment as usual (TAU).

METHODS

Sixty-two school-based clinicians in Maryland and Connecticut were randomized (37 in CBT; 25 in TAU), trained, and enrolled at least one anxious student (148 students in CBT; 68 in TAU). Students (N = 216) were ages 6-18 (mean age 10.9); 63.9% were non-Hispanic White race-ethnicity; and 48.6% were female. Independent evaluators (IEs) assessed outcomes at post treatment and at a one-year follow up. Anxiety related costs included mental health care expenses and the opportunity costs of added caregiver time and missed school days.

RESULTS

The overall M-CBT ICER value of $6917/QALY reflected both lower costs for days absent from school (mean difference: $--117 per youth; p = 0.045) but also lower QALY ratings (mean difference: -0.024; p = 0.900) compared with usual school counseling. Among youth with more severe anxiety at baseline, M-CBT had a more favorable ICER ($-22,846/QALY). Other mental health care costs were similar between groups (mean difference: $-90 per youth; p = 0.328).

DISCUSSION

Although training school clinicians in M-CBT resulted in lower costs for school absences, evidence for the cost effectiveness of a modular CBT relative to existing school treatment for pediatric anxiety disorders was not robustly supported. Findings suggest school-based M-CBT is most cost effective for youth with the highest levels of anxiety severity and that M-CBT could help reduce the costs of missed school. Interpretations are limited due to use of retrospective recall, lack of data on medication use, and small sample size.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Schools may benefit from providing specialized school-based services such as M-CBT for students with the highest levels of anxiety.

IMPLICATIONS FOR HEALTH POLICIES

Investment decisions by schools should take into account lower costs (related to school absences), the costs of training clinicians, and student access to CBT in the community.

IMPLICATIONS FOR FURTHER RESEARCH

Replication with a larger sample, service use diaries, and objective school and medical records over a longer period of time is warranted.

Cost and effectiveness of HPV vaccine delivery strategies: A systematic review

•

This review focused on implemented HPV vaccine delivery strategies and their costs.

•

Insights on the costs and effectiveness of HPV vaccination strategies are provided.

•

Access was improved by increasing the availability and the uptake of HPV vaccines.

•

Costs varied by vaccine delivery strategy and target population.

•

Lessons learned can inform efficient and equitable allocation of vaccine resources.

Fifteen years following the approval of the first human papillomavirus (HPV) vaccine, cervical cancer continues to be a significant source of morbidity and mortality among women in low-resource settings. It is the second-leading cause of cancer-related deaths in women globally and the leading cause of cancer-related deaths in Sub-Saharan Africa. Vaccine delivery and programmatic costs may hinder the distribution of HPV vaccines in low-resource settings, and ultimately influence access to HPV vaccines. While reviews have been conducted on the cost-effectiveness of HPV vaccines, little is known about the cost and effectiveness of vaccination strategies. The purpose of this systematic review was to synthesize evidence on the cost and cost-effectiveness of vaccination strategies utilized to increase access to HPV vaccines. Search queries were created for CINAHL Plus, Embase, and PubMed. Our search strategy focused on articles that contained information on HPV vaccine uptake/reach, HPV vaccination costs, or the cost-effectiveness of HPV vaccination programs. We retrieved 773 articles from the databases, assessed 251 full-texts, and included 15 articles in our final synthesis. Countries without national HPV vaccination programs aimed to identify and adopt sustainable strategies to make HPV vaccines available to adolescents through demonstration programs. In contrast, countries with national vaccination programs focused on identifying cost-effective interventions to increase vaccination rates to meet nationally recommended standards. There is a dire need for HPV vaccination programs and intervention studies tailored to settings in low- and middle-income countries to increase access to HPV vaccines. Future studies should also evaluate the cost-effectiveness of implemented strategies.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors

Background

Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics.

Methods

Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle.

Results

Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02–1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01–1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02–1.03) or Native American (IRR = 1.02, 95% CI: 1.01–1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01–1.05) and deaths (IRR = 1.04, 95% CI: 1.01–1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01–1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94–0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04–1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01–1.07) were associated with more deaths.

Conclusions

These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11205-w.

Race, ethnicity, poverty and the social determinants of the coronavirus divide: U.S. county-level disparities and risk factors

BACKGROUND

Communities with more Black or Hispanic residents have higher coronavirus rates than communities with more White residents, but relevant community characteristics are underexplored. The purpose of this study was to investigate poverty-, race- and ethnic-based disparities and associated economic, housing, transit, population health and health care characteristics.

METHODS

Six-month cumulative coronavirus incidence and mortality were examined using adjusted negative binomial models among all U.S. counties (n = 3142). County-level independent variables included percentages in poverty and within racial/ethnic groups (Black, Hispanic, Native American, Asian), and rates of unemployment, lacking a high school diploma, housing cost burden, single parent households, limited English proficiency, diabetes, obesity, smoking, uninsured, preventable hospitalizations, primary care physicians, hospitals, ICU beds and households that were crowded, in multi-unit buildings or without a vehicle.

RESULTS

Counties with higher percentages of Black (IRR = 1.03, 95% CI: 1.02-1.03) or Hispanic (IRR = 1.02, 95% CI: 1.01-1.03) residents had more coronavirus cases. Counties with higher percentages of Black (IRR = 1.02, 95% CI: 1.02-1.03) or Native American (IRR = 1.02, 95% CI: 1.01-1.04) residents had more deaths. Higher rates of lacking a high school diploma was associated with higher counts of cases (IRR = 1.03, 95% CI: 1.01-1.05) and deaths (IRR = 1.04, 95% CI: 1.01-1.07). Higher percentages of multi-unit households were associated with higher (IRR = 1.02, 95% CI: 1.01-1.04) and unemployment with lower (IRR = 0.96, 95% CI: 0.94-0.98) incidence. Higher percentages of individuals with limited English proficiency (IRR = 1.09, 95% CI: 1.04-1.14) and households without a vehicle (IRR = 1.04, 95% CI: 1.01-1.07) were associated with more deaths.

CONCLUSIONS

These results document differential pandemic impact in counties with more residents who are Black, Hispanic or Native American, highlighting the roles of residential racial segregation and other forms of discrimination. Factors including economic opportunities, occupational risk, public transit and housing conditions should be addressed in pandemic-related public health strategies to mitigate disparities across counties for the current pandemic and future population health events.

Development of an innovative curriculum-to-career transition program for nurse practitioners in primary care

BACKGROUND

Unlike physicians, there are no current requirements or funding for the post graduation training of advanced practice nurses. Given the complexity of health care, more post graduate training programs are needed to meet growing demand.

PURPOSE

A taskforce was convened to research gaps in preparation for real-world practice, as well as effective models of curricular and clinical support to promote positive patient outcomes.

METHODS

Supportive structures for advance practice nurses are dependent upon understanding the barriers, facilitators and structural support required to implement such a program.

FINDINGS

Starting a curriculum-to-career program the semester prior to graduation is a relatively untested model for advanced practitioners to receive enhanced mentored education and support to increase resiliency, reduce early burnout and burden on the health setting.

DISCUSSION

Advanced practice nurse fellowships should be considered as essential as medical residencies are for physicians in clinical practice.

Access to Direct-Acting Antiviral Treatment for Hepatitis C Virus Among Veterans With Serious Mental Illness

OBJECTIVE

This study examined whether serious mental illness is associated with initiating and with completing sofosbuvir-based treatment for hepatitis C virus (HCV) among veterans who started treatment after the Veterans Health Administration (VHA) received expanded funding for HCV care.

METHODS

Administrative health care data from fiscal years 2016-2017 revealed 4,288 treatment-naïve patients with HCV, of whom 1,311 had initiated sofosbuvir-based treatment. Dependent variables were initiation and completion of ≥8 weeks of sofosbuvir treatment. Associations with serious mental illness were estimated with adjusted odds ratios from multivariable logistic regression analyses.

RESULTS

No statistically significant differences were found in the proportion of veterans with and veterans without serious mental illness who initiated (p=0.628) or completed ≥8 weeks (p=0.301) of sofosbuvir treatment.

CONCLUSIONS

Veterans with and without serious mental illness initiated and completed sofosbuvir treatment at similar rates. The VA should continue to provide equitable access to HCV treatments and support medication adherence.

Primary surgical management of anterior pelvic organ prolapse: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP.

METHODS

We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective.

MAIN RESULTS

We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values.

CONCLUSIONS

Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty.

TWEETABLE ABSTRACT

New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.

Feasibility of Collecting Saliva for Biological Verification of Tobacco Use Status in Dental Practices and Patients' Homes: Results from the National Dental PBRN

OBJECTIVE

To evaluate the feasibility of collecting and analyzing saliva samples from dental practices and patients' homes for biochemical verification of tobacco use status.

BASIC RESEARCH DESIGN

Sub-study within single-arm, multi-center, longitudinal clinical study.

CLINICAL SETTING

Dental practices in the South Central region of the United States National Dental Practice-Based Research Network and patients' homes.

PARTICIPANTS

Fifty-five patients recruited from 30 dental practices.

INTERVENTIONS

Participants in the sub-study were instructed on saliva collection for cotinine analysis in dental practices where they enrolled in the primary study. Saliva was collected at the practices and then from patients' homes.

MAIN OUTCOME MEASURES

Feasibility for dental practice collection was define as 80% of enrolled participants having analyzable samples. For patients' home collection, feasibility was defined as 70%.

RESULTS

Forty-seven samples (i.e., 86% of those enrolled) collected in dental practices were analyzable. Twenty-one samples (i.e. 38% of those enrolled) collected in patients' homes were analyzable.

CONCLUSIONS

Collecting saliva samples for cotinine analysis from dental practices, but not from patients' homes, was feasible. Dental practices may provide an advantageous setting for biochemically verifying tobacco use status as part of clinical trials for tobacco cessation.

Reducing Preschool Behavior Problems in an Urban Mental Health Clinic: A Pragmatic, Non-Inferiority Trial

OBJECTIVE

This pragmatic, randomized, non-inferiority trial compared the effectiveness and cost of group-based parent management training with mastery-based individual coaching parent management training in a low-income, predominantly African American sample.

METHOD

Parents seeking treatment for their 2- to 5-year-old children's behavior problems in an urban fee-for-service child mental health clinic were randomized to the Chicago Parent Program (CPP; n = 81) or Parent-Child Interaction Therapy (PCIT; n = 80). Consent followed clinic intake and diagnostic assessment and parent management training was delivered by clinicians employed at the clinic. Primary outcome measures were externalizing child behavior problems, assessed at baseline and postintervention follow-up, using the Child Behavior Checklist (CBCL) and average per-participant treatment cost.

RESULTS

Data from 158 parents were analyzed. Most were mothers (75.9%), African American (70.3%), and economically disadvantaged (98.7% Medicaid insured). Of children, 58.2% were boys, and mean age was 3.6 years (SD 1.03). Based on CBCL scores, behavior problems improved in the 2 conditions (Cohen d = 0.57 for CPP and 0.50 for PCIT). CPP was not inferior to PCIT (90% CI -1.58 to 4.22) at follow-up, even after controlling for differences in treatment length (90% CI -1.63 to 4.87). Average per-participant treatment cost was higher for PCIT (mean $2,151) than for CPP (mean $1,413, 95% CI -1,304 to -170).

CONCLUSION

For parents of young children living in urban poverty, CPP is not inferior to PCIT for decreasing child behavior problems. CPP requires less time to complete and costs a third less than PCIT.

CLINICAL TRIAL REGISTRATION INFORMATION

Early Parenting Intervention Comparison (EPIC); https://clinicaltrials.gov/; NCT01517867.

Treatments for bulimia nervosa: a network meta-analysis

BACKGROUND

Bulimia nervosa (BN) is a severe eating disorder that can be managed using a variety of treatments including pharmacological, psychological, and combination treatments. We aimed to compare their effectiveness and to identify the most effective for the treatment of BN in adults.

METHODS

A search was conducted in Embase, Medline, PsycINFO, and Central from their inception to July 2016. Studies were included if they reported on treatments for adults who fulfilled diagnostic criteria for BN. Only randomised controlled trials (RCTs) that examined available psychological, pharmacological, or combination therapies licensed in the UK were included. We conducted a network meta-analysis (NMA) of RCTs. The outcome analysed was full remission at the end of treatment.

RESULTS

We identified 21 eligible trials with 1828 participants involving 12 treatments, including wait list. The results of the NMA suggested that individual cognitive behavioural therapy (CBT) (specific to eating disorders) was most effective in achieving remission at the end of treatment compared with wait list (OR 3.89, 95% CrI 1.19-14.02), followed by guided cognitive behavioural self-help (OR 3.81, 95% CrI 1.51-10.90). Inconsistency checks did not identify any significant inconsistency between the direct and indirect evidence.

CONCLUSIONS

The analysis suggested that the treatments that are most likely to achieve full remission are individual CBT (specific to eating disorders) and guided cognitive behavioural self-help, although no firm conclusions could be drawn due to the limited evidence base. There is a need for further research on the maintenance of treatment effects and the mediators of treatment outcome.

Using vignettes to assess contributions to the work of addressing child mental health problems in primary care

BACKGROUND

To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers.

METHODS

Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77% female, 58% at their site 10 or more years; 44% in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level.

RESULTS

The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50%) increase in work (95% CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff.

CONCLUSIONS

Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness

BACKGROUND

Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system.

METHODS

We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics.

RESULTS

Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk.

LIMITATIONS

This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made.

CONCLUSIONS

Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Gender differences in antipsychotics prescribed to veterans with serious mental illness

OBJECTIVE

To examine gender differences in prescribing of antipsychotic medications (APMs) according to their liability for weight gain and other metabolic side effects.

METHOD

We identified 4510 patients with schizophrenia or bipolar disorders receiving usual care in a Veterans Affairs (VA) health care network in the U.S. mid-Atlantic region who initiated treatment with an APM between October 2006 and September 2011. We used multivariable logistic regression to examine gender differences in the likelihood of incident prescription of APMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and selected Veteran demographic, mental health and physical health characteristics.

RESULTS

Overall, 58% of women were prescribed an APM with a low risk of metabolic side effects compared to 45% of men (P<.001). In multivariable analysis, women Veterans were 1.47 times as likely as men to be prescribed a low-metabolic-risk APM (95% confidence interval: 1.26-1.73, P<.001). Several demographic and clinical covariates were also independently related to prescribing of APMs by level of metabolic risk.

CONCLUSIONS

The results may suggest that prescribing choices for APMs by VA mental health prescribers and female Veterans reflect a growing awareness of the potential adverse health consequences of these treatments in women.

SCREENING FOR AND PREVALENCE OF HIV AND HEPATITIS C AMONG AN OUTPATIENT URBAN SAMPLE OF PEOPLE WITH SERIOUS MENTAL ILLNESS AND CO-OCCURRING SUBSTANCE ABUSE

BACKGROUND

To assess rates of screening and testing of HIV and HCV among those with serious mental illness and co-occurring substance use disorders.

METHODS

One hundred fifty-three people with serious mental illness and cooccurring substance use disorders completed measures and were screened for HIV and HCV.

RESULTS

Six percent were HIV positive and 25% were HCV positive. Almost a quarter reported a history of injection drug use and 86% reported a history of unprotected sexual encounters. Compared to those without a diagnosis of Hepatitis C, those diagnosed with Hepatitis C were significantly more likely to have a sexually transmitted infection, (p = 0.01), have a lifetime history of injection drug use, (p < 0.001), and a lifetime history of sniffing drugs, (p = 0.01).

CONCLUSIONS

Given the high levels of infection of HIV and HCV and high levels of transmission risk factors efforts to improve screening and provide risk reduction counseling are warranted.

Training clinicians in mental health communication skills: impact on primary care utilization

OBJECTIVE

Although it is known that children with mental health problems utilize primary care services more than most other children, it is unknown how addressing mental health problems in primary care affects children's subsequent services utilization. This study measures primary care utilization in the context of a randomized trial of a communication skills training program for primary care clinicians that had a positive impact on child mental health outcomes.

METHODS

From 2002 to 2005, 48 pediatric primary care clinicians at 13 sites in rural upstate New York, urban Maryland, and Washington, DC, were randomized to in-office training or to a control group. Consecutive primary care patients between the ages of 5 and 16 years were screened for mental health problems, as indicated by a possible or probable score on the Strengths and Difficulties Questionnaire (SDQ). For 397 screened children, primary care visits during the next 6 months were identified using chart review and administrative databases. Using generalized estimating equation regression to account for clustering at the clinician level, primary care utilization was compared by study group and SDQ status.

RESULTS

The number of primary care visits to the trained clinicians did not differ significantly from those made to control clinicians (2.5 for both groups; P = .63). Children with possible or probable SDQ scores made, on average, 0.38 or 0.65 more visits on a per child basis, respectively, during the 6-month follow-up period than SDQ unlikely children (P = .0002).

CONCLUSIONS

Seeing a trained clinician did not increase subsequent primary care utilization. However, primary care utilization was greater among children with mental health problems as measured by the SDQ. Addressing children's mental health in primary care does not increase the primary care visit burden. Research on overall health services utilization is needed.

Initiation of assertive community treatment among veterans with serious mental illness: client and program factors

OBJECTIVES

Ensuring equitable access to mental health services is a national priority. The authors examined assertive community treatment (ACT) services initiation in the Veterans Affairs (VA) health system among program-eligible patients.

METHODS

The VA's National Psychosis Registry included 6,540 patients who met program eligibility criteria (mental illness diagnosis and prior hospitalization) in fiscal year (FY) 2003 (FY 2003) and had not received VA ACT services in FY 2001-FY 2003. Receipt of VA ACT services during FY 2004 was assessed with generalized estimating equations. Independent variables included age, gender, race and ethnicity, marital status, service-connected disability benefits, substance use disorder, psychiatric inpatient days in FY 2003, distance to the nearest facility with a VA ACT team, presence of an on-site team at the facility where the last VA psychiatric hospitalization occurred, and number of open slots with the nearest ACT team.

RESULTS

A total of 452 of the eligible patients (7%) received VA ACT services in FY 2004. In multivariate analyses, older age was associated with reduced odds of receiving ACT services (odds ratio [OR]=.92 per five years); being female (OR=1.86) and having schizophrenia (OR=1.64) were positively associated with ACT services initiation. Individuals living farther from ACT sites were less likely to receive ACT services (OR=.95 per ten miles). The marginal effects of distance were most substantial in the first 30 miles and beyond 100 miles.

CONCLUSIONS

Most patients who were eligible for yet not already receiving VA ACT services went without these services in FY 2004. Geographic distance limited services initiation. Focused efforts are needed to enhance ACT services initiation and delivery, particularly for individuals in remote locations.

Examination of contingency payments to dually-diagnosed patients in a multi-faceted behavioral treatment

Contingency management (CM) may be a promising component of treatment to help dually-diagnosed patients reduce their substance use. However, most prior studies examining CM with these patients have not examined the relationships among patient variables and contingency rewards received. This study examined whether characteristics of dually-diagnosed patients were related to CM payments received in a multi-faceted program. Fifty-nine dually-diagnosed patients participated in a multimodal behavioral therapy for illicit substance use involving CM. Baseline demographic and clinical characteristics were examined as they related to receipt of payments. Demographic characteristics generally were not related to receipt of payments. Several clinical variables, including diagnosis of schizophrenia, current substance dependence, and co-morbid alcohol dependence were related to payment receipt. These results provide an important step toward understanding the characteristics of dually-diagnosed patients that predict their response to CM.

Differential effects of atypical versus typical antipsychotic medication on earnings of schizophrenia patients : estimates from a prospective naturalistic study

BACKGROUND

Rising public and private expenditure on antipsychotic medications is concentrated on the cost of second generation or 'atypical' medications, which are more expensive than first generation medications and make up a rapidly growing share of all antipsychotic prescriptions. Previous studies have examined whether the higher acquisition costs of atypicals are offset by other cost and/or utilisation benefits. This paper extends this literature by examining possible effects of atypicals on earnings and related measures of labour supply in a large naturalistic study with a long-term follow-up period.

METHODS

We analysed data on earnings and other characteristics from the Schizophrenia Care and Assessment Program (SCAP), a 3-year longitudinal study (with data collection during the years 1997-2003) of 2327 adults with schizophrenia (including schizoaffective and schizophreniform disorders) recruited from behavioural healthcare provider systems in six areas of the US. We used empirical criteria and data from the SCAP database to identify 336 patients aged < 50 years who were in the stable or 'maintenance' phase of their antipsychotic treatment during the 6 months prior to baseline. Effects of atypicals compared with typicals were estimated from Tobit regression models that included additional covariates and the baseline-dependent variable values. Regression-dependent variables were reported earnings per month, hours worked per month, days worked per month and a binary indicator of employment. To control for the effect of selection bias in choice of type of atypical, we employed an instrumental variables (IV) estimation procedure.

RESULTS

For all dependent variables, our IV Tobit regressions yielded consistently positive coefficient estimates for atypical use that were either marginally significant (p < 0.1) or significant (p < 0.05) for earnings, significant for hours and days of work and not as consistently significant for employment status. Results from these regressions imply a positive effect of atypical use on monthly earnings in the range of Dollars US 107-122. In regressions that did not control for selection bias by using IVs, coefficients for atypical use were often negative and never statistically significant.

CONCLUSIONS

Our results indicate that higher drug costs of atypicals for maintenance-phase treatment are at least partially offset by higher earnings among patients. These effects represent benefits to consumers as well as savings to taxpayer-supported income transfer programmes. Future studies should seek to determine if treatment with atypicals increases patients' earnings via better control over negative symptoms and/or improved patient cognition. Both appear to be connected with employment and labour supply in patients with schizophrenia, and both may be improved through use of atypicals.

Access to new medications to treat schizophrenia

Between 1989 and 1997, the Food and Drug Administration approved four new-generation antipsychotic medications for use in the treatment of schizophrenia. This article examines factors associated with the use of new antipsychotic medications as compared with traditional antipsychotic medications from patient interviews, medical records, and a physician survey administered at schizophrenia treatment sites around the country as part of the Schizophrenia Care and Assessment Program. The following variables were significantly associated with a higher probability of receiving an atypical antipsychotic medication in multiple regression analysis at p < .05: female, younger age, younger age of onset, non-African American, having a higher Positive and Negative Syndrome Scale-Negative Syndrome subscale score. Some physician characteristics were statistically significant in the bivariate results but not in the multivariate analyses. Access to new atypical antipsychotic medications is dependent on more than clinical characteristics. In particular, barriers to access may exist for African Americans. Physician access to information about advances in drug therapies also may play a substantial role in the rate of diffusion of new medications.

Symptom Effects on Employment in a Structural Model of Mental Illness and Treatment: Analysis of Patients with Schizophrenia

BACKGROUND: There is a long tradition in the health and mental health economics literatures of estimating the impacts of disorders on employment and earnings. Several analyses have associated mental illness with poorer labor market outcomes, often using indicators of disorders to measure mental illness, but it is unclear to what extent unobserved medical treatment biases the estimated impacts of disorders on labor market outcomes. In this study we argue that in order to judge the true employment costs of mental illness and the potential benefits of treatment it is necessary to account for the structural relationship between treatment, symptoms, and employment outcomes. AIMS OF THE STUDY: The study proposes a structural model for understanding mental illness impacts on employment and empirically estimates one element of this structural model that links symptoms of schizophrenia to patients' employment status. In addition, we use our empirical estimates to simulate employment consequences of more effective treatment and reductions in symptom levels. EMPIRICAL METHODS: Our empirical analyses use a sample of 1,643 adults with a schizophrenia diagnosis. We predict the likelihood of three outcomes - not employed, employed in a sheltered or supported job, and employed in a non-supported job. Analyses include measures of demographic characteristics, illness history, location differences, and detailed symptom measures. RESULTS: We find that negative symptoms have a substantial adverse impact on participation in both non-supported jobs and in sheltered or supported jobs. The impacts on employment of other symptoms of schizophrenia are not as large, but significant effects are also found for symptoms of depression. Simulations suggest, however, that only one-third of consumers would be employed in any type of job even given a large reduction in symptom levels. DISCUSSION: Negative symptoms are particularly important for role functioning and employment. The marginal effect on employment of a reduction in negative symptoms is several times greater than the effect of a comparable reduction in positive symptoms. Moreover, the effect of an improvement in symptoms on employment is stronger for non-supported employment than for working in sheltered or supported employment. Although commonly measured symptoms of schizophrenia impact employment, greater control of symptoms alone is unlikely to lead to large increases in employment for persons with schizophrenia in the near term. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These findings suggest that improved treatment that results in reduced symptom levels will increase rates of employment among persons with schizophrenia, but that large employment impacts probably also require more effective rehabilitative therapies that target improvement in functioning. IMPLICATION FOR POLICY: Expansions of supported employment opportunities and removal of work disincentives in public income-support programs are two additional measures that may help to increase employment participation.

Intensity and continuity of services and functional outcomes in the rehabilitation of persons with schizophrenia

OBJECTIVE

The intensity and continuity of services delivered to individual clients in a community-based psychosocial rehabilitation program were examined in relationship to functional changes in the clients that occurred during the first 12 months of the program.

METHODS

Subjects were 41 clients with schizophrenia or schizoaffective disorder who were admitted to an intensive psychosocial rehabilitation program. Measures of clinical and psychosocial functioning were derived from client interviews administered at baseline and six and 12 months later. Measures of service intensity and continuity came from data gathered daily by staff over 12 months.

RESULTS

The results supported the hypotheses that greater intensity and longitudinal continuity of services are related to more client improvement as indicated by reduced rates of hospitalization and improved psychosocial functioning after both six and 12 months. Although clients' symptom levels increased over time, a significant relationship was noted between service intensity and continuity and better symptom outcomes after 12 months. Multiple regression analyses indicated that an average of 22 percent, and as much as 28 percent, of the change in clinical and functional outcomes after 12 months of rehabilitation was explained by the intensity and longitudinal continuity of services.

CONCLUSIONS

Clients who received more contact hours with staff and who had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent-living domains and had fewer days of hospitalization. Based on these findings, clinicians, administrators, and researchers can assume that the intensity and longitudinal continuity of services are important to achieving rehabilitative outcomes in some community-based psychosocial rehabilitation models.

Macrophage-derived superoxide is not required for nitric oxide mediated tumour cell killing by RAW 264 cells

Nitric oxide, a proposed mediator of macrophage tumour cell killing, can react with superoxide to form peroxynitrite, which is capable of reacting with a variety of biological molecules. The RAW 264 murine macrophage cell line can be stimulated by cytokines and lipopolysaccharide to produce NO by induction of the inducible nitric oxide synthase. We have shown that activated RAW 264 cells are cytotoxic towards P815 murine mastocytoma cells, and that addition of a nitric oxide synthase inhibitor exerts a concentration dependent protective effect. Addition of superoxide dismutase had no effect on either RAW 264 NO production or cell killing. It was shown that RAW 264 cells do not undergo an oxidative burst. These results indicate that RAW 264 tumour cell killing is primarily a nitric oxide mediated event and does not involve macrophage-derived superoxide.

Ruthenium complexes as nitric oxide scavengers: a potential therapeutic approach to nitric oxide-mediated diseases

1. Ruthenium(III) reacts with nitric oxide (NO) to form stable ruthenium(II) mononitrosyls. Several Ru(III) complexes were synthesized and a study made of their ability to bind NO, in vitro and also in several biological systems following expression of the inducible isoform of nitric oxide synthase (iNOS). Here we report on the properties of two, related polyaminocarboxylate-ruthenium complexes: potassium chloro[hydrogen(ethylenedinitrilo)tetraacetato]ruthenate+ ++ (=JM1226; CAS no.14741-19-6) and aqua[hydrogen(ethylenedinitrilo)tetraacetato]ruthenium (=JM6245; CAS no.15282-93-6). 2. Binding of authentic NO by aqueous solutions of JM1226 yielded a product with an infrared (IR) spectrum characteristic of an Ru(II)-NO adduct. A compound with a similar IR spectrum was obtained after reacting JM1226 with S-nitroso-N-acetylpenicillamine (SNAP). 3. The effect of JM1226 or JM6245 on nitrite (NO2-) accumulation in cultures of macrophages (RAW 264 line) 18 h after stimulating cells with lipolysaccharide (LPS) and interferon-gamma (IFNgamma) was studied. Activation of RAW264 cells increased NO2- levels in the growth medium from (mean+/-1 s.e.mean) 4.9+/-0.5 microM to 20.9+/-0.4 microM. This was blocked by actinomycin D (10 microM) or cycloheximide (5 microM). The addition of JM1226 or JM6245 (both 100 microM) to activated RAW264 cells reduced NO2- levels to 7.6+/-0.2 microM and 8.8+/-0.6 microM, respectively. N(G)-methyl-L-arginine (L-NMMA; 250 microM) similarly reduced NO2- levels, to 6.1+/-0.2 microM. 4. The effect of JM1226 or JM6245 on NO-mediated tumour cell killing by LPS+IFNgamma-activated macrophages (RAW 264) was studied in a co-culture system, using a non-adherent murine mastocytoma (P815) line as the 'target' cell. Addition of JM1226 or JM6245 (both 100 microM) to the culture medium afforded some protection from macrophage-mediated cell killing: target cell viability increased from 54.5+/-3.3% to 93.2+/-7.1% and 80.0+/-4.6%, respectively (n=6). 5. Vasodilator responses of isolated, perfused, pre-contracted rat tail arteries elicited by bolus injections (10 microl) of SNAP were attenuated by the addition of JM1226 or JM6245 (10(-4) M) to the perfusate: the ED50 increased from 6.0 microM (Krebs only) to 1.8 mM (Krebs + JM6245) and from 7 microM (Krebs only) to 132 microM (Krebs + JM1226). Oxyhaemoglobin (5 microM) increased the ED50 value for SNAP from 8 microM to 200 microM. 6. Male Wistar rats were injected with bacterial LPS (4 mg kg(-1); i.p.) to induce endotoxaemia. JM1226 and JM6245 (both 100 microM) fully reversed the hyporesponsiveness to phenylephrine of tail arteries isolated from animals previously (24 h earlier) injected with LPS. Blood pressure recordings were made in conscious LPS-treated rats using a tail cuff apparatus. A single injection of JM1226 (100 mg kg(-1), i.p.) administered 20 h after LPS (4 mg kg(-1), i.p.) reversed the hypotension associated with endotoxaemia. 7. The results show that JM1226 and JM6245 are able to scavenge NO in biological systems and suggest a role for these compounds in novel therapeutic strategies aimed at alleviating NO-mediated disease states.

Increased prevalence of Listeria monocytogenes in the faeces of patients receiving long-term H2-antagonists

BACKGROUND

Human listeriosis is an uncommon infection caused by the Gram-positive organism Listeria monocytogenes.

OBJECTIVE

To investigate the effects of therapeutic gastric acid suppression on faecal isolation of L. monocytogenes and the incidence of human listeriosis.

METHODS

Five stool specimens from each of 20 patients on continuous H2-antagonist therapy and two faecal samples from each of 47 healthy controls were investigated for the presence of Listeria spp.

RESULTS

A higher faecal isolation rate of L. monocytogenes was detected amongst the patients (20%) compared with the controls (2.1%) (P < 0.025). All subjects with stools positive for Listeria spp. were female, this sex difference being significant in the patient group (P < 0.0036) compared with controls. No patient, however, developed listeriosis.

CONCLUSION

Patients on long-term gastric acid suppressive therapy may be at increased risk of faecal carriage of L. monocytogenes.

Mutations in some Polycomb group genes of Drosophila interfere with regulation of segmentation genes

Mutations in several Polycomb (Pc) group genes cause maternal-effect or zygotic segmentation defects, suggesting that Pc group genes may regulate the segmentation genes of Drosophila. We show that individuals doubly heterozygous for mutations in polyhomeotic and six other Pc group genes show gap, pair rule, and segment polarity segmentation defects. We examined double heterozygous combinations of Pc group and segmentation mutations for enhancement of adult and embryonic segmentation defects. Posterior sex combs and polyhomeotic interact with Krüppel and enhance embryonic phenotypes of hunchback and knirps, and polyhomeotic enhances even-skipped. Surprisingly, flies carrying duplications of extra sex combs (esc), that were heterozygous for mutations of even-skipped (eve), were extremely subvital. Embryos and surviving adults of this genotype showed strong segmentation defects in even-numbered segments. Antibody studies confirm that expression of eve is suppressed by duplications of esc. However, esc duplications have no effect on other gap or pair rule genes tested. To our knowledge, this is only the second triplo-abnormal phenotype associated with Pc group genes. Duplications of nine other Pc group genes have no detectable effect on eve. Expression of engrailed (en) was abnormal in the central nervous systems of most Pc group mutants. These results support a role for Pc genes in regulation of some segmentation genes, and suggest that esc may act differently from other Pc group genes.

Psychosocial functioning and subjective experience in schizophrenia

This study examines the relationship between psychosocial functioning and subjective experience in 193 individuals diagnosed with schizophrenia or schizoaffective disorder according to Research Diagnostic Criteria. Psychosocial functioning was measured as work functioning, social functioning, living situation, symptomatology, and intrapsychic aspects of the deficit syndrome. Subjective experience consisted of measures of self-esteem, satisfaction with life, and subjective distress. Multivariate analyses resulted in two major findings. The first finding is a model of psychosocial functioning that consists of two factors: disorder-related variables (symptomatology and intrapsychic deficits) and functional status variables (work, social, and living situation). The second major finding is a two-tiered model of the relationship between psychosocial functioning and subjective experience. The model suggests a primary and pervasive relationship between the disorder-related variables and subjective experience and a secondary and less pronounced relationship between functional status variables and subjective experience. The implications of these findings for treatment and rehabilitation and for the study of subjective experience in schizophrenia are discussed.

Genetic analysis of the additional sex combs locus of Drosophila melanogaster

Additional sex combs (Asx) is a member of the Polycomb group of genes, which are thought to be required for maintenance of chromatin structure. To better understand the function of Asx, we have isolated nine new alleles, each of which acts like a gain of function mutation. Asx is required for normal determination of segment identity. AsxP1 shows an unusual phenotype in that anterior and posterior homeotic transformations are seen in the same individuals, suggesting that AsxP1 might upset chromatin structure in a way that makes both activation and repression of homeotic genes more difficult. Analysis of embryonic and adult phenotypes of Asx alleles suggests that Asx is required zygotically for determination of segment number and polarity. The expression pattern of even-skipped is altered in Asx mutant embryos, suggesting that Asx is required for normal expression of this gene. We have transposon-tagged the Asx gene, and can thus begin molecular analysis of its function.

Erysipelas: facial lymphangitis

Two cases of facial lymphangitis have been described, and the pathophysiology of erysipelas has been discussed. Now rarely observed by hospital residents, this potentially serious infection can create considerable diagnostic confusion in medical as well as dental services. Rapid response of erysipelas to penicillin therapy is the modern expectation.