Urine sulfated and nonsulfated bile acids as a diagnostic test for liver disease in cats

Urine bile acid (UBA) tests reflecting "average" serum bile acid (SBA) concentrations may have greater practical utility than paired SBA samples in cats. This study evaluated whether urine sulfated bile acids (USBAs), urine nousulfated bile acids (UNSBAs), or a combined approach had a clinical utility equivalent to SBAs. Routine serum biochemistry tests, SBA concentrations, and urine samples were collected from 54 cats with hepatobiliary disease, 17 cats with nonhepatic disorders, and 8 healthy cats. UBAs were measured by a quantitative enzymatic colorimetric method, and results were normalized with urine creatinine (UCr) concentrations. Significantly higher values occurred in cats with liver disease than in cats without liver disease for USBA : UCr, UNSBA:UCr, and (USBA and UNSBA) : UCr, P < .05 each. UBA tests with diagnostic performance (sensitivity [SS], specificity [SP], and positive and negative predictive values [PV+ and PV-]) equivalent to SBAs were the UNSBA : UCr and the combined test (SS: 87, 87 versus 85; SP: 88, 88 versus 88; PV+: 96, 96 versus 96; PV-: 68, 65 versus 68; UNSBA : UCr, [USBA, and UNSBA]: UCr versus SBA, respectively). Clinical applications of the UNSBA : UCr or the combined (USBA and UNSBA) : UCr test should be useful as convenient diagnostic tests for identifying cats with liver disease and high SEA concentrations.

Vocational outcomes among formerly homeless persons with severe mental illness in the access program

OBJECTIVE

This study examined the vocational outcomes of 4,778 formerly homeless individuals with severe mental illness who were enrolled in the Access to Community Care and Effective Services and Support (ACCESS) program, a multisite demonstration project designed to provide services to this population.

METHODS

Participants were interviewed at the time of enrollment and again three months and 12 months later by trained researchers who were not part of the treatment team to determine their employment status. At 12 months, participants were also asked about the types of services they had received during the past 60 days. Multiple logistic regression analysis was used to predict employment at 12 months.

RESULTS

ACCESS participants reported receiving relatively few job-related services. Nonetheless, modest but significant increases occurred between baseline and three months and between three months and 12 months in the total proportion of participants who were employed and who were employed full-time and in hourly earnings and estimated monthly earnings. The number of hours worked per week increased significantly between three months and 12 months. When the analysis controlled for site, study condition (whether the ACCESS site received or did not receive extra funds to improve service integration), minority status, addiction treatment, and mental health treatment, participants who were employed at 12 months were more likely to have received job training and job placement services.

CONCLUSIONS

Programs that work with homeless mentally ill persons may better serve their clients by placing as great an emphasis on providing employment services as on providing housing and clinical treatment.

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES

This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness.

STUDY SETTING

A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites.

DATA SOURCES

Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews.

RESEARCH DESIGN

Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement.

PRINCIPAL FINDINGS

Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support.

CONCLUSION

Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES

This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes.

METHODS

As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site).

RESULTS

Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies.

CONCLUSIONS

Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

Impact of representative payees on substance use by homeless persons with serious mental illness

OBJECTIVE

Assignment of representative payees, third parties responsible for managing clients' funds, has been proposed to counter potential use of public support payments for abused substances by people with severe mental illness and substance use disorders. This study examines substance use outcomes in a sample of homeless persons with serious mental illness and substance use disorders, some of whom were assigned representative payees.

METHODS

The subjects were participating in the Access to Community Care and Effective Services and Supports (ACCESS) program, a federally funded demonstration program on integrating service systems. Clients were assessed at baseline and three months after case management services were initiated. Factorial repeated-measures analysis of covariance was used to examine substance use among four client subgroups, two of which had payees and two of which did not.

RESULTS

Clients in this sample (N = 1,348) showed significant improvement on all measures of substance use over the first three months in the program. Those with payees showed no greater improvement in substance abuse than those without payees, although they did have fewer days of homelessness.

CONCLUSIONS

This study failed to find evidence that merely adding external money management services to existing services improves substance abuse outcomes among clients who had dual diagnoses and were homeless. Besides assigning a payee, structured behavioral interventions may be needed to produce additional clinical benefits.

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports

The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.