The Impact of Market Factors on Meaningful Use of Electronic Health Records Among Primary Care Providers: Evidence From Florida Using Resource Dependence Theory and Information Uncertainty Perspective

BACKGROUND

Using federal funds from the 2009 Health Information Technology for Economic and Clinical Health Act, the Centers for Medicare and Medicaid Services funded the 2011-2021 Medicaid electronic health record (EHR) incentive programs throughout the country.

OBJECTIVE

Identify the market factors associated with Meaningful Use (MU) of EHRs after primary care providers (PCPs) enrolled in the Florida-EHR incentives program through Adopting, Improving, or Upgrading (AIU) an EHR technology.

RESEARCH DESIGN

Retrospective cohort study using 2011-2018 program records for 8464 Medicaid providers.

MAIN OUTCOME

MU achievement after first-year incentives.

INDEPENDENT VARIABLES

The resource dependence theory and the information uncertainty perspective were used to generate key-independent variables, including the county's rurality, educational attainment, poverty, health maintenance organization penetration, and number of PCPs per capita.

ANALYTICAL APPROACH

All the county rates were converted into 3 dichotomous measures corresponding to high, medium, and low terciles. Descriptive and bivariate statistics were calculated. A generalized hierarchical linear model was used because MU data were clustered at the county level (level 2) and measured at the practice level (level 1).

RESULTS

Overall, 41.9% of Florida Medicaid providers achieved MU after receiving first-year incentives. Rurality was positively associated with MU ( P <0.001). Significant differences in MU achievements were obtained when we compared the "high" terciles with the "low" terciles for poverty rates ( P =0.002), health maintenance organization penetration rates ( P =0.02), and number of PCPs per capita ( P =0.01). These relationships were negative.

CONCLUSIONS

Policy makers and health care managers should not ignore the contribution of market factors in EHR adoption.

The impact of county-level factors on meaningful use of electronic health records (EHRs) among primary care providers

This study examines the impact of county-level factors on "meaningful use" (MU) of electronic health records (EHRs) for 8415 primary care providers (PCPs) that enrolled in the Florida Medicaid EHR Incentive Program through adopting, improving, or upgrading (AIU) a certified EHR technology. PCPs received incentive payments at enrollment and if they used their EHRs in meaningful ways; ways that benefit patients and providers alike they received additional payments. We conducted a retrospective cohort study of these providers over the 2011-2018 period while linking their records to other state data. We used the core constructs of the resource dependence theory (RDT), a well-established organization theory in business management, to operationalize the county-level variables. These variables were rurality, poverty, educational attainment, managed care penetration, changes in population, and number of PCPs per capita. The unit of analysis was provider-years. For practical and computational purposes, all the county variables were dichotomized. We used analysis of variance (ANOVA) to test for differences in MU attestation rates across each county variable. Odds ratios and corresponding 95% confidence intervals were derived from pooled logistic regressions using generalized estimated equations (GEE) with the binomial family and logit link functions. Clustered standard errors were used. Approximately 42% of these providers attested to MU after receiving first-year incentives. Rurality and poverty were significantly associated with MU. To some degree, managed care penetration, change in population size, and number of PCPs per capita were also associated with MU. Policy makers and healthcare managers should not ignore the contribution of county-level factors in the diffusion of EHRs among physician practices. These county-level findings provide important insights about EHR diffusion in places where traditionally underserved populations live. This county-perspective is particularly important because of the potential for health IT to enable public health monitoring and population health management that might benefit individuals beyond the patients treated by the Medicaid providers.

Provider participation in the Florida Medicaid Promoting Interoperability program: Practice characteristics, meaning use attestations, and incentive payments

OBJECTIVE

The objective of this study was to quantify the rate of provider participation beyond year 1 incentive in the Florida Medicaid Promoting Interoperability (PI) program, formerly the Electronic Health Record Incentive program, and identify the provider and practice characteristics associated with Meaningful Use attestations.

METHODS AND MATERIALS

We conducted a retrospective cohort study using the 2011-2018 records from the PI program, Provider Participation Database. Bivariate associations between Meaningful Use and categorical and ordinal variables were tested using Chi-square and Mantel-Haenszel Chi-square, respectively, with results informing logistic regressions. Adjusted odds ratios and 95 % confidence intervals are reported.

RESULTS

We found that 42.56 % of Florida Medicaid providers achieved Meaningful Use after receiving first-year incentives. Logistic regression showed that pediatricians represented the largest percentage of providers who achieved Meaningful Use (65.06 %) while dentists had the lowest Meaningful Use (7.78 %). We also found that certain geographic areas and various EHR vendors were associated with higher rates of providers Meaningful Use attestation.

DISCUSSION

Although the PI program successfully influenced the adoption of a basic EHR system, low Meaningful Use attestations have inadvertently created a digital "advanced use" divide among providers who serve large numbers of Medicaid patients. This is concerning because advanced EHR functions are necessary precursors to address unmet socioeconomic needs to reduce health disparities.

CONCLUSION

Florida has distributed over $100 million to Medicaid providers who ultimately did not achieve Meaningful Use after collecting their first-year incentive. Policy interventions that can promote advanced EHR use functions are necessary to optimize technology in low-resourced practice settings where the potential benefits are greater.

Costs of substance use disorders from claims data for Medicare recipients from a population-based sample

Medicare spending is projected to increase over the next decade, including for substance use disorders (SUD). Our objective was to determine whether SUDs are associated with higher six-year Medicare costs (1999-2004) among participants in the Baltimore Epidemiologic Catchment Area (ECA) Study. Medicare claims data for the years 1999-2004 from the Centers for Medicare and Medicaid Services were linked to four waves of data from the Baltimore ECA cohort collected between 1981 and 2005 (n=566). A generalized linear model with a log link and gamma distribution was used to examine direct Medicare costs associated with SUD status. Medicare recipients with no history of SUD had mean six-year costs of $42,576. Those with a history of SUD based on both Baltimore ECA and Medicare data, or based on Medicare claims data alone, had significantly higher costs ($98,754 and $64,876, respectively). A history of SUD based solely on Baltimore ECA data alone had lower average costs ($25,491). Findings indicate that Medicare costs differ by source of SUD diagnosis when comparing treatment versus survey data. This may have future implications for projecting Medicare costs among SUD individuals as healthcare coverage expands under the Affordable Care Act.

COSTS OF DEPRESSION FROM CLAIMS DATA FOR MEDICARE RECIPIENTS IN A POPULATION-BASED SAMPLE

BACKGROUND

Many persons with depressive disorder are not treated and associated costs are not recorded.

AIMS OF THE STUDY

To determine whether major depressive disorder (MDD) is associated with higher medical cost among Medicare recipients.

METHODS

Four waves of the Baltimore-Epidemiologic Catchment Area (Baltimore ECA) Study conducted between 1981 and 2004 were linked to Medicare claims data for the years 1999 to 2004 from the Centers for Medicare and Medicaid Services (CMS). Generalized linear models specified with a gamma distribution and log link function were used to examine direct medical care costs associated with MDD.

RESULTS

Medicare recipients with no history of MDD in either the ECA or CMS data had mean six-year medical costs of US $40,670, compared to $87,445 for Medicare recipients with MDD as recorded in CMS data and $43,583 for those with MDD as recorded in Baltimore-ECA data. Multivariable regressions found that compared to Medicare recipients with no history of depression, those with depression identified in the CMS data had significantly higher medical costs; about 1.87 times (95% confidence interval (CI) 1.32 to 2.67) higher. Medicare recipients with a history of depression identified in the ECA data were no more likely to have higher costs than were Medicare recipients with no history of depression (relative ratio 1.33, 95% CI 0.87 to 2.02).

DISCUSSION

Medicare recipients with a history of depression identified in claims data had significantly higher medical costs than recipients with no history of depression. However, no significant differences were found between Medicare recipients with depression in the community-based Baltimore ECA data and those with no history of depression. The results show that the source of diagnosis, in treatment versus survey data, produces differences in results as regards costs.

LIMITATIONS

This study involved only Medicare recipients with claims data over the six years 1999 to 2004. Many of the ECA respondents were too young to qualify for Medicare.

IMPLICATIONS FOR HEALTH POLICY

Depressive disorder involves substantial medical care costs. The findings provide information on the economic burden of depression, an important but often omitted dimension and perspective of the burden of mental illnesses.

Children's emotional and behavioral problems and their mothers' labor supply

It has been documented that about 20% of children and adolescents suffer from a diagnosable mental or addictive disorder in the United States. The high prevalence of children’s emotional and behavioral problems (EBP) might have a negative effect on their mothers’ labor market outcomes because children with EBP require additional time for treatment. However, these children may require additional financial resources, which might promote mothers’ labor supply. Previous studies have only considered chronic conditions in analyzing the impact of children’s health on parental work activities. Moreover, most of these studies have not accounted for endogeneity in children’s health. This article estimates the effects of children’s EBP on their mothers’ labor supply by family structure while accounting for endogeneity in children’s health. We used the 1997 and 2002 Child Development Supplements (CDS) to the Panel Study of Income Dynamics (PSID). We used probit and bivariate probit models to estimate mothers’ probability of employment, and tobit and instrumental variable tobit models to estimate the effects of children’s EBP on their mothers’ work hours. Findings show negative effects of children’s EBP on their married mothers’ employment and on their single mothers’ work hours.

The influence of religious attendance on smoking

Generalized linear models were used to assess the relationship between religious attendance and lifetime smoking status among middle-aged adults (n = 666) sampled from waves three (1993 to 1996) and four (2004 to 2005) of the Baltimore Epidemiologic Catchment Area (ECA) study. Religious attendance once per week or greater as compared to never was inversely associated with smoking status. Future research should explore potential mediating factors of the association between religious attendance and smoking among middle-aged adults in order to gain a greater understanding of the mechanisms underlying this relationship.

FUNDING

NIMH grant DA026652; NIDA grant T32DA007292.

Interim versus standard methadone treatment: a benefit-cost analysis

A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4 months of 12 months of methadone treatment or 12 months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4- and 12-month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant. For the combined sample, there was a pre- to post-treatment net benefit of $1470 (95% CI: -$625; $3584) and a benefit-cost ratio of 1.5 (95% CI: 0.8, 2.3), but using our conservative approach to calculating benefits, these values were not significant.

Lifetime depressive disorders and adherence to anti-retroviral therapy in HIV-infected Ugandan adults: a case-control study

BACKGROUND

There is limited information on the impact of lifetime depressive disorders on adherence to ART.

AIM

We examined the association between lifetime depressive disorders and adherence to anti-retroviral therapy (ART) among a rural clinic-based HIV positive population. We further explored whether this association was mediated by current depression and moderated by gender.

METHODS

Two hundred HIV positive individuals who had<95% adherence and two hundred HIV positive individuals who had ≥95% adherence were screened for depression using the self-reporting questionnaire (SRQ-20) and evaluated with the Mini neuropsychiatric interview (MINI). Multivariate logistic regression was used to assess the association between lifetime depressive disorders and adherence to ART. The logistic regression model of Baron and Kenny was used to evaluate the mediating effect of current depression. Hierarchical binomial logistic regression was used to evaluate the moderating effect of gender.

RESULTS

HIV positive individuals with lifetime depressive disorders had an increased risk of non-adherence to ART after controlling for education status, income, self-efficacy, perceived social support, cognitive impairment and current alcohol use disorders [AOR=1.68, 95%CI (1.02-2.79), p=0.04]. This association was stronger in females than males [AOR= 4.76, 95%CI (1.52-14.97), p=0.008].

LIMITATIONS

Findings cannot be generalized to ART naïve individuals or those using ART for less than six months.

CONCLUSION

Lifetime depressive disorders are associated with increased risk of non-adherence to ART in rural women with HIV infection in southern Uganda. Detection and treatment of depression can potentially improve adherence with HIV treatment in this setting.

Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico

OBJECTIVE

Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico.

METHODS

We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted.

RESULTS

The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of-$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY.

CONCLUSIONS

These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.

The economic cost of substance abuse treatment in the state of Florida

OBJECTIVE

Public and private stakeholders of substance abuse treatment services require economic cost data to guide program evaluations and funding decisions.

BACKGROUND

Rigorous cost assessments have been conducted for several treatment programs across the United States, but a systematic and comprehensive evaluation of programs in a particular state has never been attempted.

RESEARCH DESIGN

The present study recruited all publicly funded treatment programs in the State of Florida and administered the Brief Drug Abuse Treatment Cost Analysis Program.

SUBJECTS

A total of 175 programs participated in the study, representing a 71% response rate.

MEASURES

Annual, weekly, and episode costs are estimated by modality.

CONCLUSION

The study procedures and empirical findings from this research can be used by program evaluators and government officials in Florida and other states as they develop service reimbursement algorithms and initiate more extensive evaluations of publicly funded substance abuse treatment programs.

Cross-cultural adaptation and validation of the self-reporting questionnaire among HIV+ individuals in a rural ART program in southern Uganda

BACKGROUND

HIV treatment programs are in need of brief, valid instruments to identify common mental disorders such as depression.

AIM

To translate and culturally adapt the Self-Reporting Questionnaire (SRQ-20) for use in Uganda and to investigate its psychometric properties in this setting.

METHODS

Following an initial translation of the SRQ-20 from English to Luganda, key informant interviews and focus-group discussions were used to produce a culturally adapted version of the instrument. The adapted SRQ-20 was administered to 200 HIV-positive individuals in a rural antiretroviral therapy program in southern Uganda. All study participants were also evaluated by a psychiatric clinical officer with the Mini International Neuropsychiatric Interview (MINI). Receiver-operating-characteristic analysis was used to examine the sensitivity and specificity of the SRQ-20 compared to the clinical diagnosis generated by the MINI.

RESULTS

The prevalence estimates of any depressive disorder and current depression were 24% (n = 48) and 12% (n = 24), respectively. The SRQ-20 scores discriminated well between subjects with and without current depression based on the MINI, with an area under the curve of 0.92, as well as between subjects with and without any current or past depressive disorder, with an area under the curve of 0.75. A score of 6 or more had 84% sensitivity and 93% specificity for current depression, and 75% sensitivity and 90% specificity for any depressive disorder.

CONCLUSION

The SRQ-20 appears to be a reliable and valid screening measure for depression among rural HIV-positive individuals in southern Uganda. The use of this screening instrument can potentially improve detection and management of depression in this setting.

[Cost effectiveness of posaconazole versus fluconazole/itraconazole in the prophylactic treatment of invasive fungal infections in Mexico]

Cost effectiveness of posaconazole versus fluconazole/itraconazole therapy in the prophylaxis against invasive fungal Infections among high-risk neutropenic patients in Mexico.

OBJECTIVE

To estimate the cost effectiveness and long-term combined effects of Posaconazole versus fluconazole/itraconazole (standard azole) therapy in the prophylaxis against invasive fungal Infections among high-risk neutropenic patients in Mexico.

METHODS

A previously validated Markov model was used to compare the projected lifetime costs and effects of two theoretical groups of patients, one receiving Posaconazole and the other receiving standard azole. The model estimates total costs, numbers of IFIs, and QALY per patient in each prophylaxis group. To extrapolate trial results to a lifetime horizon, the model was extended with one-month Markov cycles in which mortality risk is specific to the underlying disease. Data on the probabilities of IFI were obtained from Study Protocol PO1899. Drug costs were taken from average wholesale drug reports for 2009. Cost and health effects were discounted at 5% according to the Mexican guideline. The analysis was conducted from the Mexican healthcare perspective using 2008 unit cost prices.

RESULTS

Our model projects an accumulated cost to the Mexican healthcare system per patient receiving the Posaconazol regimen of $US 5,634 compared to $US 7,463 for the standard azole regimen. The accumulated discounted effect is 3.13 LY or 2.25 QALYs per patient receiving Posaconazol, compared to 2.96 LY or 2.13 QALYs per patient receiving standard azole. Posaconazol remained the dominant strategy across each scenario. Probabilistic sensitivity analysis tested numerous assumptions about the model cost and efficacy parameters and found that the results were robust to most changes.

CONCLUSION

Posaconazole provides modest incremental benefits compared with standard azole therapy in the prophylaxis against IFIs among high-risk neutropenic patients. Routine Posaconazole use appears a cost saving when the likelihood of IFIs or the cost of treatment medications is high.

[Cost effectiveness of treatment with salmeterol/fluticasone compared to montelukast for the control of persistent asthma in children]

OBJECTIVE

To assess the incremental cost-effectiveness of SFC compared with MON for the control of persistent asthma in children.

METHODS

We conducted an economic evaluation on a 12-week prospective randomized open-label parallel-group comparison of SFC versus MON in children with symptomatic asthma receiving inhaled corticosteroids and short-acting β2-agonists. Asthma-related medication, unscheduled physician contacts and hospitalizations were collected prospectively. The main effectiveness measure was percentage of asthma-controlled week with no short-acting β2-agonist use during the study period. The analysis was conducted from the Mexican healthcare perspective using 2010 unit cost prices, and only direct costs were considered, all costs are reported in US dollar. . The model was made fully probabilistic to reflect the joint uncertainty in the model parameters.

RESULTS

Over the whole treatment period, the median percentages of asthma-controlled weeks were 83.3% in the SFC group and 66.7% in the MON group (SFC-MON difference, 16.7%; 95% CI, 8.3-16.7; P < 0.001 in favor of SFC). The mean total cost of the SFC regimen was $ 2,323 compared with $ 3,230 for the MON regimen. The SFC was the dominant strategy (both more effective and less expensive) using the SFC was associated with an incremental cost per additional asthma-controlled of $ (5,467). Probabilistic sensitivity analysis tested numerous assumptions about the model cost and efficacy parameters and found that the results were robust to most changes.

CONCLUSIONS

This analysis demonstrates that, compared with MON, SFC may be cost saving from the Mexican health care perspective for the treatment of pediatric patients with asthma. SFC provided a reduction in the number of severe exacerbations, frequent asthma symptoms and rescue medication use. Incremental cost-effectiveness analysis indicated the dominance of SFC because of both lower costs and greater efficacy.

Perceived risk associated with ecstasy use: a latent class analysis approach

This study aims to define categories of perceived health problems among ecstasy users based on observed clustering of their perceptions of ecstasy-related health problems. Data from a community sample of ecstasy users (n=402) aged 18 to 30, in Ohio, was used in this study. Data was analyzed via Latent Class Analysis (LCA) and Regression. This study identified five different subgroups of ecstasy users based on their perceptions of health problems they associated with their ecstasy use. Almost one third of the sample (28.9%) belonged to a class with "low level of perceived problems" (Class 4). About one fourth (25.6%) of the sample (Class 2), had high probabilities of "perceiving problems on sexual-related items", but generally low or moderate probabilities of perceiving problems in other areas. Roughly one-fifth of the sample (21.1%, Class 1) had moderate probabilities of perceiving ecstasy health-related problems in all areas. A small proportion of respondents (11.9%, Class 5) had high probabilities of reporting "perceived memory and cognitive problems", and of perceiving "ecstasy-related problems in all areas" (12.4%, Class 3). A large proportion of ecstasy users perceive either low or moderate risk associated with their ecstasy use. It is important to further investigate whether lower levels of risk perception are associated with persistence of ecstasy use.

Adolescent drug dealing and race/ethnicity: a population-based study of the differential impact of substance use on involvement in drug trade

BACKGROUND

Among adolescents, peers are an important source of drug procurement. However, little is known about factors associated with youths' involvement in drug trade.

OBJECTIVES

The aim of the study is to identify substance use behaviors and contextual factors related to drug dealing among Black and White adolescents.

METHODS

The sample consisted of 13,706 White and Black youths who completed the National Survey on Drug Use and Health. Separate backward logistic regression was used to identify substance use behaviors and contextual factors associated with drug dealing among Black and White youths.

RESULTS

Among White youths, drug dealing was associated with use of marijuana, hallucinogens, cocaine, prescription drug misuse, availability of cocaine, and socioeconomic status (SES). Among Black youths, marijuana use and availability of crack and marijuana were associated with drug dealing.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

For White youths, substance use seems to be more relevant to drug dealing. Consequently, preventing and treating substance abuse may reduce involvement in the illegal distribution of drugs among White youths. More research is needed to identify risk and protective factors for drug dealing among Black adolescents.

Disparities in adequate mental health care for past-year major depressive episodes among white and non-white youth

OBJECTIVE

Following efforts made in recent years to have effective mental health treatments based on evidence-based guidelines, a working-definition of a minimum level of 'adequate mental health care (AMHC)' for serious mental illness (SMI) was developed in the literature. However, little is known about racial/ethnic disparities in receipt of adequate mental health care for SMI. The objective of this study was to examine disparities among Whites and non-Whites in receiving adequate mental health care for past-year major depressive episodes (MDE).

METHODS

The study sample was 1,688 US youth 12 to 17 years old affected by MDE in the 2005 National Survey on Drug Use and Health. We estimated the percentages of Whites and non-Whites that received adequate mental health care for MDE and estimated the correlates of receipt of adequate mental health care for the full sample and by racial/ethnic groups.

RESULTS

About 34 percent of the sample received adequate mental health care; but separate analyses indicate that a significantly higher proportion of Whites (36 percent) received adequate mental health care relative to non-Whites (28 percent). The odds of receiving adequate mental health care for past-year MDE for Whites were 1.5 times that of non-Whites (p = 0.01).

CONCLUSION

As more adolescents of diverse racial/ethnic backgrounds are identified to access mental health Treatment services, it might be important to examine the degree to which treatment should be tailored to engage and retain specific racial/ethnic groups to get the minimum of adequate mental health care.

Disparities in adequate mental health care for past-year major depressive episodes among Caucasian and Hispanic youths

OBJECTIVE

Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes.

METHODS

Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined.

RESULTS

Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians.

CONCLUSIONS

As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

The association of ecstasy use and academic achievement among adolescents in two U.S. national surveys

The association of ecstasy (3, 4-methylenedioxymethamphetamine, MDMA) use with low academic achievement was examined in two nationally representative surveys of adolescents. We tested whether associations with low academic achievement were of similar magnitude or of stronger magnitude for ecstasy versus marijuana use (without ecstasy use), alcohol/tobacco use (without other drug use) and non-drug use in adolescence. Data from the adolescents in the 2002-2005 National Survey of Drug Use and Health (NSDUH, n=65,294) and from the 2001-2003 Youth Risk Behavior Survey (YRBS, n=27,592) were analyzed via weighted logistic regression models. Ecstasy, marijuana, and alcohol/tobacco use were associated with moderate and low academic achievement among adolescents in both surveys. Moreover, ecstasy was more strongly associated with low academic achievement and reporting that school gave no grades than alcohol/tobacco in both samples and than marijuana (NSDUH sample only). Prevention programs should inform adolescents that ecstasy use might impair their academic achievement.

Mental Health Care for Youth: Predictors of Use are not always the same as Predictors of Volume

This study identifies determinants of adolescents' propensity to use outpatient mental care as well as factors predicting number of visits after contact with a provider was made. We examined three types of treatment outlets: day treatment program (DTP); mental health clinic (MHC); and private specialty services (PSS). Among youth, 1.6% visited DTP; 2.3% visited MHC; and 11.1% had PSS; with overlaps in services utilization. Results from multivariable logistic regressions indicate that most of the individual characteristics differentiated youth on odds of using MHC and PSS, but not DTP. Health status, alcohol dependence, drug dependence, and problematic conduct behaviors and having Medicaid increased the odds of using all three services. Censored regressions used to model number of visits among service users found that girls consistently used more visits than boys. The results suggest that policies that encourage seeking help to a mental care provider may be in instances different from those aimed at motivating retention in treatment.

Adolescent ecstasy and other drug use in the National Survey of Parents and Youth: the role of sensation-seeking, parental monitoring and peer's drug use

The association between high sensation-seeking, close friends' drug use and low parental monitoring with ecstasy (MDMA) use in adolescence was examined in a sample of US household-dwelling adolescents aged 12-18 years (N=5049). We also tested whether associations were of stronger magnitude than associations between these correlates and marijuana or alcohol/tobacco use in adolescence. Data from Round 2 of the National Survey of Parents and Youth (NSPY) Restricted Use Files (RUF) was analyzed via Jackknife weighted multinomial logistic regression models. High sensation-seekers were more likely to be ecstasy, marijuana, and alcohol/tobacco users, respectively, as compared to low sensation-seekers. High sensation-seeking and close friends' drug use were more strongly associated with ecstasy as compared to marijuana and alcohol/tobacco use. Low parental monitoring was associated with marijuana use and alcohol/tobacco use and there was a trend for it to be associated with ecstasy use. Ecstasy use is strongly associated with peer drug use and more modestly associated with high sensation-seeking. School prevention programs should target high-sensation-seeking adolescents and also encourage them to affiliate with non-drug using peers.

The cost of twin pregnancy: maternal and neonatal factors

OBJECTIVE

The purpose of this study was to evaluate factors affecting birth charges in twin pregnancies.

STUDY DESIGN

Clinical and financial data were obtained on 1486 twin pregnancies delivered between 1995 to 2002 at medical centers in Maryland, Florida, Michigan, and South Carolina. Maternal and neonatal length of stay (LOS) and charges were modeled by gestational age and other risk factors using a general linear model.

RESULTS

Maternal and infant birth admission LOS and charges increased significantly with a decline in gestational age. Maternal LOS and charges were also significantly increased by cesarean delivery and preeclampsia. Newborn LOS and charges increased significantly by monochorionicity and slowed growth between 20 to 28 weeks. For mother and infants, the shortest LOS and lowest birth charges were at 37 to 38 weeks.

CONCLUSION

These findings reflect the substantial maternal and neonatal morbidity associated with twin pregnancies, and demonstrate that 37 to 38 weeks is their optimal gestation.

Labor Supply of Poor Residents in Metropolitan Miami, Florida: The Role of Depression and the Co-Morbid Effects of Substance Use

BACKGROUND: Depression represents one of the most common behavioral health problems among the workforce in the United States, with about 1 in every 20 employees experiencing this condition. A recent study estimated that in 1990 the economic costs of depressive disorders in the American workplace amounted to as much as $43 billion, with absenteeism alone accounting for $12 billion. Recently, economists have been focusing attention on the relationship between mental health and labor supply, but a lack of quality data sets containing detailed information on mental health and labor market variables represents a significant barrier to rigorous research. AIMS OF THE STUDY: The primary aims of the present study were to (i) examine the relationship between depression and employment, (ii) conditional on being employed, estimate the effect of depression on annual weeks worked, and (iii) examine the stability of the model estimates to the co-morbid effects of substance use (illicit drugs and alcohol), which has been consistently found to be a correlate of depression. DATA: The study used a unique set of survey data collected between 1996 and 1997 in crime-ridden and low-income neighborhoods of Miami-Dade County, Florida. A targeted sampling strategy was used to recruit chronic drug users (including injection drug users) and non-drug users to examine local health care delivery system characteristics in relation to the population of substance users. The final analysis sample for the present study included 1,274 adults, aged 18 to 65. Depression status was measured from the 20-item Zung Self-Rating Depression Scale (SDS) that classified 384 individuals as depressed and 890 as non-depressed. According to the definition developed by the U.S. Office of National Drug Control Policy for chronic drug use (CDU), about 46 percent of the depressed individuals were found to be CDUs compared to 30 percent of the non-depressed sample. The survey instrument collected information on alcohol use and problem drinking as defined by the 10-item Michigan Alcoholism Screening Test (MAST-10). Based on criteria defined in the MAST-10, 26 percent of the depressed individuals were problematic alcohol users (PAUs) compared to about 16 percent of the non-depressed sample.METHODS: The labor supply measures included employment in the past 30 days and number of weeks worked in the past 12 months. The analysis estimated a univariate probit model of employment as well as a bivariate probit model of depression and employment, which accounted for the possible correlation between the unobserved determinants of depression and employment. The annual weeks worked specification was estimated by a standard Tobit model as well as an instrumental variable (IV) Tobit model, which, in addition to the censoring of the observations, accounted for the possible endogeneity of depression. The stability of the estimated effects of depression to comorbid illicit drug and alcohol use was assessed, by controlling for CDU and PAU in these models. RESULTS: Results from both the univariate probit and the bivariate probit models indicate that depression significantly decreased the probability of being employed. Specifically, depression reduced the probability of employment by an average of 19 percentage points in both models, from a sample average of 43 percent for the non- depressed to 24 percent for the depressed. Estimates from the Tobit models revealed that depression also significantly reduced the number of weeks worked. Conditional on being employed, depressed individuals worked an average of 7 fewer annual weeks than the non-depressed sample in the univariate Tobit model and 8 fewer weeks in the IV Tobit. The findings also showed that the effects of depression on employment and annual weeks worked may be over-estimated if the analysis does not account for the comorbid influence of substance use. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results suggest that prevention and/or treatment of mental health problems such as depression may yield economic benefits by promoting employment and enhancing labor supply. While expansion of public mental health services may not lead to overall increases in employment, it may be justified on social grounds given the high unemployment rate in low-income and crime-ridden neighborhoods. Further insights can be gained by estimating these models with national and international data if one applies appropriate econometric tools to account for complex sample designs.

Problem drinking, health services utilization, and the cost of medical care

The purpose of this study was to examine the relationships between problem drinking, health services utilization, and the cost of medical care in a community-based setting. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-administered questionnaire designed to obtain important information on demographics, health status, morbidity, health care utilization, drug and alcohol use, and related lifestyle behaviors. The survey instrument also included the 10-item Michigan Alcoholism Screening Test (MAST-10), which was used to identify problematic alcohol users (PAUs). The empirical findings indicated that PAUs had a significantly higher number of outpatient visits, more emergency room episodes, and more admissions to a hospital than a combined group of nondrinkers and nonproblematic alcohol users (NPAUs). Analyses of total health care cost showed that the estimated differential in total cost for PAUs during the past year, including the interaction effect with problematic drug use, was $367. The total cost (full effect) for PAUs was composed of a main effect ($984) and an interaction effect (-$617). These findings have implications for substance abuse interventions and health care policy.