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Riley J, Drake RE, Frey W, Goldman HH, Becker DR, Salkever D, Marrow J, Borger C, Taylor J, Bond GR, Karakus M. Helping People Denied Disability Benefits for a Mental Health Impairment: The Supported Employment Demonstration. Psychiatr Serv 2021; 72:1434-1440. [PMID: 33971731 DOI: 10.1176/appi.ps.202000671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Social Security Administration demonstration projects that are intended to help people receiving disability benefits have increased employment but not the number of exits from disability programs. The Supported Employment Demonstration (SED) is a randomized controlled trial (RCT) of services for individuals with mental health problems before they enter disability programs. The SED aims to provide health, employment, and other support services that help them become self-sufficient and avoid entering disability programs. The target population is people who have been denied Social Security disability benefits for a presumed psychiatric impairment. Thirty community-based programs across the United States serve as treatment sites; inclusion in the SED was based on the existence of high-fidelity employment programs that use the individual placement and support model, the ability to implement team-based care, and the willingness to participate in a three-armed RCT. In the SED trial, one-third of 2,960 participants receive services as usual, one-third receive services from a multidisciplinary team that includes integrated supported employment, and one-third receive services from a similar team that also includes a nurse care coordinator for medication management support and medical care. The goals of the study are to help people find employment, attain better health, and delay or avoid disability program entry. This article introduces the SED.
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Affiliation(s)
- Jarnee Riley
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Robert E Drake
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - William Frey
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Howard H Goldman
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Deborah R Becker
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - David Salkever
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Jocelyn Marrow
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Christine Borger
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Jeffrey Taylor
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Gary R Bond
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
| | - Mustafa Karakus
- Department of Social Policy and Economics Research, Westat Corporation, Rockville, Maryland
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Mendelson T, Clary LK, Sibinga E, Tandon D, Musci R, Mmari K, Salkever D, Stuart EA, Ialongo N. A randomized controlled trial of a trauma-informed school prevention program for urban youth: Rationale, design, and methods. Contemp Clin Trials 2020; 90:105895. [PMID: 31786150 PMCID: PMC8100974 DOI: 10.1016/j.cct.2019.105895] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Youth in disadvantaged urban areas are frequently exposed to chronic stress and trauma, including housing instability, neighborhood violence, and other poverty-related adversities. These exposures increase risk for emotional, behavioral, and academic problems and ultimately, school dropout. Schools are a promising setting in which to address these issues; however, there are few universal, trauma-informed school-based interventions for urban youth. METHODS/DESIGN Project POWER (Promoting Options for Wellness and Emotion Regulation) is a randomized controlled trial testing the impact of RAP Club, a trauma-informed intervention for eighth graders that includes mindfulness as a core component. Students in 32 urban public schools (n = 800) are randomly assigned to either RAP Club or a health education active control group. We assess student emotional, behavioral, and academic outcomes using self-report surveys and teacher ratings at baseline, post-intervention, and 4-month follow up. Focus groups and interviews with students, teachers, and principals address program feasibility, acceptability, and fidelity, as well as perceived program impacts. Students complete an additional self-report survey in ninth grade. Schools provide students' academic and disciplinary data for their seventh, eighth, and ninth grade years. In addition, data on program costs are collected to conduct an economic analysis of the intervention and active control programs. DISCUSSION Notable study features include program co-leadership by young adults from the community and building capacity of school personnel for continued program delivery. In addition to testing program impact, we will identify factors related to successful program implementation to inform future program use and dissemination.
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Affiliation(s)
- Tamar Mendelson
- Johns Hopkins Bloomberg School of Public Health, United States.
| | - Laura K Clary
- Johns Hopkins Bloomberg School of Public Health, United States
| | - Erica Sibinga
- Johns Hopkins Bloomberg School of Public Health, United States
| | | | - Rashelle Musci
- Johns Hopkins Bloomberg School of Public Health, United States
| | - Kristin Mmari
- Johns Hopkins Bloomberg School of Public Health, United States
| | - David Salkever
- Johns Hopkins Bloomberg School of Public Health, United States
| | | | - Nick Ialongo
- Johns Hopkins Bloomberg School of Public Health, United States
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Abstract
The Social Security Administration's Mental Health Treatment Study (MHTS) produced positive mental health, employment, and quality of life outcomes for people on Social Security Disability Insurance (SSDI). The investigators discuss major policy implications. First, because integrated, evidence-based mental health and vocational services produced clinical and societal benefits, the authors recommend further service implementation for this population. Second, because provision of these services did not reduce SSDI rolls, the authors recommend future research on prevention (helping people avoid needing SSDI) rather than rehabilitation (helping beneficiaries leave SSDI). Third, because integrating mental health, vocational, and general medical services was extremely difficult, the authors recommend a multifaceted approach that includes streamlined funding and infrastructure for training and service integration. Fourth, because insurance coverage for people with disabilities during the MHTS (pre-Affordable Care Act) was chaotic, the authors recommend that financing strategies emphasize functional-not just traditional clinical-outcomes.
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Affiliation(s)
- Robert E Drake
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - William Frey
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Mustafa Karakus
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - David Salkever
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Gary R Bond
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Howard H Goldman
- Dr. Drake and Dr. Bond are with the Psychiatric Research Center, Dartmouth College, Lebanon, New Hampshire (e-mail: ). Dr. Frey and Dr. Karakus are with Westat, Rockville, Maryland. Dr. Salkever is with the Department of Public Policy, University of Maryland-Baltimore County, Baltimore. Dr. Goldman, who is editor of Psychiatric Services, is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore
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Salkever D, Gibbons B, Ran X. Erratum to: Do Comprehensive, Coordinated, Recovery-Oriented Services Alter the Pattern of Use of Treatment Services? Mental Health Treatment Study Impacts on SSDI Beneficiaries’ Use of Inpatient, Emergency, and Crisis Services. J Behav Health Serv Res 2014. [DOI: 10.1007/s11414-014-9399-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Previous research found a positive effect of Level-I trauma centres on return to work outcomes for patients 18-64 years old who were mainly working before injury. Trauma centres were compared to hospitals that differed on average in characteristics such as size and staffing, among others. Thus, a portion of the effect found could be due to general differences in hospital variables rather than the special characteristics of Level I trauma centres. Comparing Level I trauma centres to other Teaching hospitals provides a more refined test of the effect of these centres on return-to-work outcomes. METHODS The National Study on the Costs and Outcomes of Trauma (NSCOT) is the main source of data for our empirical investigation. We used non-linear instrumental variables methods to control for unobserved characteristics and restrict the sample to teaching hospitals. The first method is the two-stage residual inclusion model in which we identify the effect using the proportion of resident population served by Helicopter Ambulance Services (at the state level) as an instrumental variable. The second method is a recursive bivariate probit model. RESULTS We found that treatment at Level-I trauma centres has a positive effect on return to work outcomes three months after injury. The estimated effect is statistically significant and positive, but lower than the estimate that did not focus on teaching hospitals. CONCLUSIONS A previous study found positive effects of treatment at a Level-I trauma centre on return-to-work outcomes, however, a portion of the effect found was due to general differences in hospital variables.
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Affiliation(s)
- Sergio I Prada
- PROESA & Department of Economics, Universidad ICESI, Calle 18 No. 122-135, Office B-102, Cali, Colombia.
| | - David Salkever
- Department of Public Policy, University of Maryland, Baltimore County (UMBC), Public Policy Bldg. Rm. 418, 1000 Hilltop Circle, Baltimore, MD 21250, United States.
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Rm. 482, Baltimore, MD 21205, United States.
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Stuart EA, DuGoff E, Abrams M, Salkever D, Steinwachs D. Estimating causal effects in observational studies using Electronic Health Data: Challenges and (some) solutions. EGEMS (Wash DC) 2013; 1. [PMID: 24921064 PMCID: PMC4049166 DOI: 10.13063/2327-9214.1038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Electronic health data sets, including electronic health records (EHR) and other administrative databases, are rich data sources that have the potential to help answer important questions about the effects of clinical interventions as well as policy changes. However, analyses using such data are almost always non-experimental, leading to concerns that those who receive a particular intervention are likely different from those who do not, in ways that may confound the effects of interest. This paper outlines the challenges in estimating causal effects using electronic health data, and offers some solutions, with particular attention paid to propensity score methods that help ensure comparisons between similar groups. The methods are illustrated with a case study describing the design of a study using Medicare and Medicaid administrative data to estimate the effect of the Medicare Part D prescription drug program among individuals with serious mental illness.
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Affiliation(s)
- Elizabeth A Stuart
- Department of Mental Health, Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, 8 Floor, Baltimore, MD 21205,
| | - Eva DuGoff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Michael Abrams
- The Hilltop Institute, University of Maryland Baltimore County
| | - David Salkever
- Department of Public Policy, University of Maryland Baltimore County
| | - Donald Steinwachs
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
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Drake RE, Frey W, Bond GR, Goldman HH, Salkever D, Miller A, Moore TA, Riley J, Karakus M, Milfort R. Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work. Am J Psychiatry 2013; 170:1433-41. [PMID: 23929355 DOI: 10.1176/appi.ajp.2013.13020214] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.
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Abstract
A recent policy analysis argued that expanding access to evidence-based supported employment can provide savings in major components of social costs. This article extends the scope of this policy analysis by placing the argument within a recently developed economic framework for social cost-effectiveness analysis that defines a program's social cost impact as its effect on net consumption of all goods and services. A total of 27 studies over the past two decades are reviewed to synthesize evidence of the social cost impacts of expanding access to the individual placement and support model of supported employment (IPS-SE). Most studies have focused primarily on agency costs of providing IPS-SE services, cost offsets when clients shift from "traditional" rehabilitation to IPS-SE, and impacts on clients' earnings. Because costs and cost offsets are similar in magnitude, incremental costs of expanding services to persons who would otherwise receive traditional services are probably small or even negative. The population served by an expansion could be sizable, but the feasibility of a policy targeting IPS-SE expansion in this way has yet to be demonstrated. IPS-SE has positive impacts on competitive job earnings, but these may not fully translate into social cost offsets. Additional empirical support is needed for the argument that large-scale expansion would yield substantial mental health treatment cost offsets. Other gaps in evidence of policy impacts include take-up rate estimates, cost impact estimates from longer-term studies (exceeding two years), and longer-term studies of whether IPS-SE prevents younger clients from becoming recipients of Supplemental Security Income or Social Security Disability Insurance
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Affiliation(s)
- David Salkever
- Department of Public Policy, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, USA.
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Thompson HJ, Weir S, Rivara FP, Wang J, Sullivan SD, Salkever D, MacKenzie EJ. Utilization and costs of health care after geriatric traumatic brain injury. J Neurotrauma 2012; 29:1864-71. [PMID: 22435729 DOI: 10.1089/neu.2011.2284] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite the growing number of older adults experiencing traumatic brain injury (TBI), little information exists regarding their utilization and cost of health care services. Identifying patterns in the type of care received and determining their costs is an important first step toward understanding the return on investment and potential areas for improvement. We performed a health care utilization and cost analysis using the National Study on the Costs and Outcomes of Trauma (NSCOT) dataset. Subjects were persons 55-84 years of age with TBI treated in 69 U.S. hospitals located in 14 states (n=414, weighted n=1038). Health outcomes, health care utilization, and 1-year costs of care following TBI in 2005 U.S. dollars were estimated from hospital bills, patient surveys, medical records, and Medicare claims data. The subjects were further analyzed in three subgroups (55-64, 65-74, and 75-84 years of age). Unadjusted cost models were built, followed by a second set of models adjusting for demographic and pre-injury health status. Those in the oldest category (75-84 years) had significantly higher numbers of re-hospitalizations, home health care visits, and hours per week of unpaid care, and significantly lower numbers of physician and mental health professional visits than younger age groups (age 55-64 and 65-74 years). Significant age-related differences were seen in all health outcomes tested at 12 months post-injury except for incidence of depressive symptoms. One-year total treatment costs did not differ significantly across age categories for brain-injured older adults in either the unadjusted or adjusted models. The unadjusted total mean 1-year cost of care was $77,872 in persons aged 55-64 years, $76,903 in persons aged 65-74 years, and $72,733 in persons aged 75-84 years. There were significant differences in cost drivers among the age groups. In the unadjusted model index hospitalization costs and inpatient rehabilitation costs were significantly lower in the oldest age category, while outpatient care costs and nursing home stays were lower in the younger age categories. In the adjusted model, in addition to these cost drivers, re-hospitalization costs were significantly higher among those 75-84 years of age, and receipt of informal care from friends and family was significantly different, being lowest among those aged 65-74 years, and highest among those aged 75-84 years. Identifying variations in care that these patients are receiving and determining the costs versus benefits is an important next step in understanding potential areas for improvement.
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Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA 98195-7266, USA.
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Abstract
BACKGROUND Injury is the leading cause of death for persons aged 1-44 years in the United States. Injuries have a substantial economic cost. For that reason, regional systems of trauma care in which the more acutely injured patients are transported to Level-I (L-I) trauma centers (TCs) has been widely advocated. However, the cost of TC care is high, raising questions about the value of such an approach. OBJECTIVES To study L-I TC effectiveness and study return-to-work (RTW) outcomes. RESEARCH DESIGN Using data from National Study on the Costs and Outcomes of Trauma, the authors address the issue of selection bias by comparing naive estimates to matching techniques, as well as to nonlinear instrumental variable models (2SRI) and bivariate probit estimators. SUBJECTS Individuals ages 18-64 who were mainly working before traumatic injury. Patients selected for the study were treated at 69 hospitals located in 12 states in the United States. N = 1790. MEASURES Treatment is binary indicator on whether treated at L-I TC. Outcome is binary indicator on whether returned to work within 3 months after injury. Covariates include: demographics, pre-injury characteristics (job, health and insurance status), injury descriptors, other income sources, etc. RESULTS Across all models that control for unobserved factors, the authors find that L-I TC treatment is positively associated with RTW within 3 months after injury. The estimated average marginal effect of treatment on the probability of RTW ranges from 23 to 38 percentage points. CONCLUSIONS Benefits of L-I TC care extend beyond mortality and morbidity.
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Affiliation(s)
- Sergio I Prada
- Research Center for Social Protection and Health Economics (PROESA), University Icesi, Cali, Colombia.
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Ascher-Svanum H, Zhu B, Faries DE, Salkever D, Slade EP, Peng X, Conley RR. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry 2010; 10:2. [PMID: 20059765 PMCID: PMC2817695 DOI: 10.1186/1471-244x-10-2] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 01/07/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the direct cost of relapse and the predictors of relapse during the treatment of patients with schizophrenia in the United States. METHODS Data were drawn from a prospective, observational, noninterventional study of schizophrenia in the United States (US-SCAP) conducted between 7/1997 and 9/2003. Patients with and without relapse in the prior 6 months were compared on total direct mental health costs and cost components in the following year using propensity score matching method. Baseline predictors of subsequent relapse were also assessed. RESULTS Of 1,557 participants with eligible data, 310 (20%) relapsed during the 6 months prior to the 1-year study period. Costs for patients with prior relapse were about 3 times the costs for patients without prior relapse. Relapse was associated with higher costs for inpatient services as well as for outpatient services and medication. Patients with prior relapse were younger and had onset of illness at earlier ages, poorer medication adherence, more severe symptoms, a higher prevalence of substance use disorder, and worse functional status. Inpatient costs for patients with a relapse during both the prior 6 months and the follow-up year were 5 times the costs for patients with relapse during the follow-up year only. Prior relapse was a robust predictor of subsequent relapse, above and beyond information about patients' functioning and symptom levels. CONCLUSIONS Despite the historical decline in utilization of psychiatric inpatient services, relapse remains an important predictor of subsequent relapse and treatment costs for persons with schizophrenia.
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Affiliation(s)
- Haya Ascher-Svanum
- US Outcomes Research, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285, USA.
| | - Baojin Zhu
- US Statistics, Lilly USA, LLC, Lilly Corporate Center, Indianapolis, IN 46285, USA
| | - Douglas E Faries
- US Statistics, Lilly USA, LLC, Lilly Corporate Center, Indianapolis, IN 46285, USA
| | - David Salkever
- Department of Public Policy, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - Eric P Slade
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA,VA VISN 5 Mental Illness Research, Education, and Clinical Center, US Department of Veterans Affairs, 10 North Greene Street, Baltimore, MD 21201, USA
| | - Xiaomei Peng
- US Statistics, Lilly USA, LLC, Lilly Corporate Center, Indianapolis, IN 46285, USA
| | - Robert R Conley
- US Medical Division, Lilly USA, LLC, Lilly Corporate Center, Indianapolis, IN 46285, USA
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Zhu B, Ascher-Svanum H, Faries DE, Peng X, Salkever D, Slade EP. Costs of treating patients with schizophrenia who have illness-related crisis events. BMC Psychiatry 2008; 8:72. [PMID: 18727831 PMCID: PMC2533651 DOI: 10.1186/1471-244x-8-72] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 08/26/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Relatively little is known about the relationship between psychosocial crises and treatment costs for persons with schizophrenia. This naturalistic prospective study assessed the association of recent crises with mental health treatment costs among persons receiving treatment for schizophrenia. METHODS Data were drawn from a large multi-site, non-interventional study of schizophrenia patients in the United States, conducted between 1997 and 2003. Participants were treated at mental health treatment systems, including the Department of Veterans Affairs (VA) hospitals, community mental health centers, community and state hospitals, and university health care service systems. Total costs over a 1-year period for mental health services and component costs (psychiatric hospitalizations, antipsychotic medications, other psychotropic medications, day treatment, emergency psychiatric services, psychosocial/rehabilitation group therapy, individual therapy, medication management, and case management) were calculated for 1557 patients with complete medical information. Direct mental health treatment costs for patients who had experienced 1 or more of 5 recent crisis events were compared to propensity-matched samples of persons who had not experienced a crisis event. The 5 non-mutually exclusive crisis event subgroups were: suicide attempt in the past 4 weeks (n = 18), psychiatric hospitalization in the past 6 months (n = 240), arrest in the past 6 months (n = 56), violent behaviors in the past 4 weeks (n = 62), and diagnosis of a co-occurring substance use disorder (n = 413). RESULTS Across all 5 categories of crisis events, patients who had a recent crisis had higher average annual mental health treatment costs than patients in propensity-score matched comparison samples. Average annual mental health treatment costs were significantly higher for persons who attempted suicide ($46,024), followed by persons with psychiatric hospitalization in the past 6 months ($37,329), persons with prior arrests ($31,081), and persons with violent behaviors ($18,778). Total cost was not significantly higher for those with co-occurring substance use disorder ($19,034). CONCLUSION Recent crises, particularly suicide attempts, psychiatric hospitalizations, and criminal arrests, are predictive of higher mental health treatment costs in schizophrenia patients.
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Affiliation(s)
- Baojin Zhu
- Eli Lilly and Company, Indianapolis, USA.
| | | | | | | | - David Salkever
- University of Maryland, Baltimore County (UMBC), Department of Public Policy, Baltimore, USA
| | - Eric P Slade
- University of Maryland School of Medicine, Baltimore, USA,U.S. Department of Veterans Affairs, VA VISN5 Mental Illness Research and Education Clinical Center, Baltimore, USA
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Salkever D, Slade E, Karakus M. Differential effects of atypical versus typical antipsychotic medication on earnings of schizophrenia patients : estimates from a prospective naturalistic study. Pharmacoeconomics 2006; 24:123-39. [PMID: 16460134 DOI: 10.2165/00019053-200624020-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- David Salkever
- Department of Public Policy, University of Maryland-Baltimore County, Baltimore, Maryland 21250, USA.
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Abstract
PURPOSE To compare economic aspects of equipment configurations, productivity levels, and patient waiting times in the performance of computed radiography (CR) and direct radiography (DR). MATERIALS AND METHODS The study received internal review board exemption status, without the need for informed patient consent. Data from four study sites were used to calculate the CR-DR crossover point (defined as the point at which the cost-effectiveness of DR equals that of CR) and CR-DR annual cost differentials. Analyzed variables included equipment and operating costs, examination volumes, and productivity. A program was developed to simulate patient arrival times, number of patient examinations, and patient waiting times on the basis of average annualized parameters for each of the four clinics. Sensitivity analyses were conducted to assess utilization rates and determine cost optimization. Utilization rates were compared with the number of excess long-stay CR patients (ie, patients who spent more than 30 minutes waiting in the radiology department prior to CR examination) and with the cost (per excess long-stay CR patient who waited more than 60 minutes) averted by using DR. RESULTS Excess annual costs for DR over CR at the four sites ranged from $50,757 to $75,303. At extrapolated levels of economic penalties for long waiting times, the crossover point at which the DR cost became justifiable was when CR capacity utilization rates approached or exceeded 80%. CONCLUSION In the current practice environment, with capacity utilization rates well below 80%, CR is likely to be a more cost-effective technology for the majority of general radiography providers.
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Affiliation(s)
- Bruce I Reiner
- Department of Radiology, Veterans Affairs Maryland Healthcare System, Baltimore, MD, USA.
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Harkness J, Newman SJ, Salkever D. The cost-effectiveness of independent housing for the chronically mentally ill: do housing and neighborhood features matter? Health Serv Res 2004; 39:1341-60. [PMID: 15333112 PMCID: PMC1361073 DOI: 10.1111/j.1475-6773.2004.00293.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the effects of housing and neighborhood features on residential instability and the costs of mental health services for individuals with chronic mental illness (CMI). DATA SOURCES Medicaid and service provider data on the mental health service utilization of 670 individuals with CMI between 1988 and 1993 were combined with primary data on housing attributes and costs, as well as census data on neighborhood characteristics. Study participants were living in independent housing units developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness in four of nine demonstration cities between 1988 and 1993. STUDY DESIGN Participants were assigned on a first-come, first-served basis to housing units as they became available for occupancy after renovation by the housing providers. Multivariate statistical models are used to examine the relationship between features of the residential environment and three outcomes that were measured during the participant's occupancy in a study property: residential instability, community-based service costs, and hospital-based service costs. To assess cost-effectiveness, the mental health care cost savings associated with some residential features are compared with the cost of providing housing with these features. DATA COLLECTION/EXTRACTION METHODS Health service utilization data were obtained from Medicaid and from state and local departments of mental health. Non-mental-health services, substance abuse services, and pharmaceuticals were screened out. PRINCIPAL FINDINGS Study participants living in newer and properly maintained buildings had lower mental health care costs and residential instability. Buildings with a richer set of amenity features, neighborhoods with no outward signs of physical deterioration, and neighborhoods with newer housing stock were also associated with reduced mental health care costs. Study participants were more residentially stable in buildings with fewer units and where a greater proportion of tenants were other individuals with CMI. Mental health care costs and residential instability tend to be reduced in neighborhoods with many nonresidential land uses and a higher proportion of renters. Mixed-race neighborhoods are associated with reduced probability of mental health hospitalization, but they also are associated with much higher hospitalization costs if hospitalized. The degree of income mixing in the neighborhood has no effect. CONCLUSIONS Several of the key findings are consistent with theoretical expectations that higher-quality housing and neighborhoods lead to better mental health outcomes among individuals with CMI. The mental health care cost savings associated with these favorable features far outweigh the costs of developing and operating properties with them. Support for the hypothesis that "diverse-disorganized" neighborhoods are more accepting of individuals with CMI and, hence, associated with better mental health outcomes, is mixed.
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Affiliation(s)
- Joseph Harkness
- Institute for Policy Studies, Johns Hopkins University, 3400 N. Charles St., 543 Wyman Park Building, Baltimore, MD 21218, USA
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Slade E, Salkever D. Symptom Effects on Employment in a Structural Model of Mental Illness and Treatment: Analysis of Patients with Schizophrenia. J Ment Health Policy Econ 2001; 4:25-34. [PMID: 11967463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/19/2001] [Accepted: 05/31/2001] [Indexed: 02/24/2023]
Abstract
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.
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Affiliation(s)
- Eric Slade
- Assistant Professor,Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, Room 433, Baltimore, MD 21205-1901, USA, Tel. +1 410-614-2602, Fax +1 410-955-3249,
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Salkever D, Domino ME, Burns BJ, Santos AB, Deci PA, Dias J, Wagner HR, Faldowski RA, Paolone J. Assertive community treatment for people with severe mental illness: the effect on hospital use and costs. Health Serv Res 1999; 34:577-601. [PMID: 10357291 PMCID: PMC1089024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE To determine the effect of the Program for Assertive Community Treatment (PACT) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness, and to test for variations in this effect with program staffing levels and patient characteristics such as race and age. DATA SOURCES/STUDY SETTING Data are taken from a randomized trial of PACT in Charleston, South Carolina for 144 patients recruited from August 1989 through July 1991. STUDY DESIGN Subjects were randomly assigned either to one of two PACT programs or to usual care at a local mental health center. Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis. DATA COLLECTION METHODS Data were obtained from Medicaid claims, chart reviews, subject, case manager, and family interviews; searches of the computerized patient and financial databases of the South Carolina Department of Mental Health and relevant hospitals; and searches of the hard copy and computerized financial databases of the two major local hospitals providing inpatient psychiatric care. PRINCIPAL FINDINGS PACT participants were about 40 percent less likely to be hospitalized during the follow-up period. The effect was stronger for older patients. Lower PACT client/staff ratios also reduced the risk of hospitalization. No evidence of differential race effects was found. Given some hospital use, PACT did not influence the number of days of use. CONCLUSIONS Controlling for other covariates, PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics. This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to-date CMHC office-based case management program.
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Affiliation(s)
- D Salkever
- Department of Health Policy and Management and Center for Research on Services for Severe Mental Illness, Johns Hopkins University, Baltimore, MD 21205, USA
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Mick SS, Morlock LL, Salkever D, de Lissovoy G, Malitz F, Wise CG, Jones A. Strategic activity and financial performance of U.S. rural hospitals: a national study, 1983 to 1988. J Rural Health 1999; 10:150-67. [PMID: 10138031 DOI: 10.1111/j.1748-0361.1994.tb00225.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study examines the effect of 13 strategic management activities on the financial performance of a national sample of 797 U.S. rural hospitals during the period of 1983-1988. Controlled for environment-market, geographic-region, and hospital-related variables, the results show almost no measurable effect of strategic adoption on rural hospital profitability and liquidity. Where statistically significant relationships existed, they were more often negative than positive. These findings were not expected; it was hypothesized that positive effects across a broad range of strategies would emerge, other things being equal. Discussed are possible explanations for these findings as well as their implication for a rural health policy relying on individual rural hospital strategic adaptation to environmental change.
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Affiliation(s)
- S S Mick
- School of Public Health, University of Michigan, Ann Arbor 48109
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Mick SS, Morlock LL, Salkever D, de Lissovoy G, Malitz FE, Wise CG, Jones A. Rural hospital administrators and strategic management activities. Hosp Health Serv Adm 1999; 38:329-51. [PMID: 10128118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This study examines the association of characteristics of rural hospital administrators and the adoption of seven strategic activities in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Based on the premise that managerial activities can affect organizational change, we test five hypotheses relating head administrator characteristics to strategic adaptation, controlling for environment-market and hospital-related variables. Bivariate analysis of the strategic adoption showed a positive association with administrative turnover and a negative association with head administrator age. Multivariate logistic regression showed that only high levels of turnover were associated with strategic activities, net of control variables. The implications of these findings and the lack of predictive power of other rural hospital administrator characteristics--especially affiliation with the American College of Healthcare Executives--are discussed within the context of a "strategic management policy" for rural hospitals.
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Affiliation(s)
- S S Mick
- Department of Health Services Management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109
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Mick SS, Morlock LL, Salkever D, de Lissovoy G, Malitz FE, Wise CG, Jones AS. Horizontal and vertical integration-diversification in rural hospitals: a national study of strategic activity, 1983-1988. J Rural Health 1999; 9:99-119. [PMID: 10126240 DOI: 10.1111/j.1748-0361.1993.tb00502.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study examines both the magnitude of and factors influencing the adoption of 13 horizontal and vertical integration and diversification strategies in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Using organization theory, hypotheses were posed relating environmental and market factors, geographic location, and hospital characteristics to the adoption of horizontal and vertical integration and diversification. Results indicate that only one of 13 strategies was adopted by more than 50 percent of all rural hospitals during the study period, and that most of the directional hypotheses were not confirmed using Cox's proportional hazards models. In particular, environmental and market factors were unrelated to the strategies studied. Issues of methodology and theory are discussed; however, during an historically turbulent period, both relatively low levels of rural hospital strategic activities and lack of predictive power of the theory suggest caution in relying heavily on a policy for rural hospital survival that is dependent on individual market-oriented strategic behavior.
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Affiliation(s)
- S S Mick
- School of Public Health, University of Michigan, Ann Arbor 48109
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Mick SS, Morlock LL, Salkever D, deLissovoy G, Malitz FE, Jones AS. Rural hospital-based alcohol and chemical abuse services: availability and adoption, 1983-1988. J Stud Alcohol 1993; 54:488-501. [PMID: 8393500 DOI: 10.15288/jsa.1993.54.488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Data from a 1983-88 retrospective panel study of 797 rural (non-Metropolitan Statistical Area) U.S. hospitals revealed that less than one in five (18.7%) had any alcohol and chemical abuse (ACA) service. About one-third of both inpatient and outpatient services had been established during the study period, but few hospitals not offering these services planned to offer them in the immediate future. These findings support other studies that the availability of such services may not meet population need or demand, although non-hospital-sponsored services might partially fill the gap. Bivariate analysis showed that hospital locations in counties that were more densely populated, had higher per capita income and had more physicians per 1,000 population were positively associated with ACA services. Hospitals that were in the New England, Mid-Atlantic, East North Central census divisions, and were large according to number of beds, presence of psychiatric services, availability of psychiatrists and other nonphysician personnel, certain organizational arrangements and strategic management activities were positively associated with ACA services. Multivariable logistic regression suggested the presence of psychiatric services as a key correlate of ACA services, and the scarcity of psychiatric personnel in rural areas appears to have been a major reason for the infrequency of rural hospital-sponsored ACA services.
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Affiliation(s)
- S S Mick
- School of Public Health, University of Michigan, Ann Arbor 48109-2029
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23
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Horgan C, Salkever D. The demand for outpatient mental health care from nonspecialty providers. Adv Health Econ Health Serv Res 1986; 8:211-33. [PMID: 10312958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Yinger N, Osborn R, Salkever D, Sirageldin I. Third world family planning programs: measuring the costs. Popul Bull 1983; 38:1-36. [PMID: 12279374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
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Breslau N, Salkever D, Staruch KS. Women's labor force activity and responsibilities for disabled dependents: a study of families with disabled children. J Health Soc Behav 1982; 23:169-183. [PMID: 6213703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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