Comparison of medical treatment of patients with schizophrenia in general practitioners' clinics versus mental health clinics: A cohort study

OBJECTIVES

Individuals with schizophrenia have more cardiometabolic comorbidities than the general population, live about twenty years less and consume more medical services. They are treated at general practitioners' clinics (GPCs) or at mental health clinics (MHCs). In this cohort study we investigated the association between patients' main treatment setting, cardiometabolic comorbidities and medical services utilization.

METHODS

Demographics, healthcare services utilization, cardiometabolic comorbidities and medication prescriptions of patients with schizophrenia were retrieved from an electronic database for the period 1.1.2011 to 31.12.2012 and compared between patients treated mostly in MHCs (N = 260) and those treated mostly in GPCs (N = 115).

RESULTS

GPC patients tended to be older (mean age 39.8 ± 13.7 vs. 34.6 ± 12.3 yrs., p < 0.0001), of lower socioeconomic status (42.6% vs 24.6%, p = 0.001) and have more cardiometabolic diagnoses (hypertension: 19.1% vs 10.8%, diabetes mellitus: 25.2% vs 17.0%, p < 0.05) than MHC patients. The former received more cardiometabolic disorder medications and utilized more secondary and tertiary medical services. Charlson Comorbidity Index (CCI) was higher in the GPC group than in the MHC group (1.8 ± 1.9 vs.1.2 ± 1. 6, p < 0.0001). A multivariate binary logistic regression analysis, adjusted for age, sex, SES and CCI found lower adjusted odds ratio for the MHC group versus the GPC group, of visiting an EMD, a specialist or to be hospitalized.

CONCLUSIONS

The current study highlights the critical importance of integrating GPCs and MHCs, thus offering patients combined physical and mental care at a single location. More studies on the potential benefits of such integration to patients' health are warranted.

Treatment outcome of an intensive psychiatric home treatment for children and adolescents: a non-randomized controlled pilot evaluation

Home treatment (HT) may offer an effective and cost-efficient alternative to inpatient treatment for children and adolescents with acute mental disorders. This study introduces and evaluates a pilot HT project from Bern, Switzerland, with HT completely replacing an inpatient treatment. A total of n = 133 children and adolescents with acute mental disorders and inpatient treatment needs were treated either in the new HT program (n = 37) or in an active control group with inpatient treatment as usual (I-TAU, n = 96). Psychopathological burden was assessed by the Health of the Nation Outcome Scale for Children and Adolescents clinician-rated (HoNOSCA) and self-rated (HoNOSCA-SR) at the time of admission and at discharge. Treatment effects were assessed and compared using Augmented Inverse Probability Weights to adjust for baseline differences and to control for treatment duration. Participants ranged in age from 6 to 17 years (M = 13.71 years, SD = 2.93), 54% were female. HT resulted in significant improvements in the HoNOSCA (d = 0.79, p < .001) and HoNOSCA-SR (d = 0.63, p = .006). No significant differences on treatment effects were observed between HT and the reference group I-TAU in the HoNOSCA (d = 0.01, p = .96) or the HoNOSCA-SR (d = 0.11, p = .63). Overall, results indicate HT to be an effective alternative for children and adolescents with acute mental health disorders instead of hospitalization. Further evaluation with random group allocation and long-term follow-up should attempt to replicate and extend the current findings.

[Pain therapy care in Germany-Do patients receiving day care differ from those receiving outpatient or inpatient care at the start of treatment? : A further evaluation based on the KEDOQ-pain data set]

The direct comparison of day care pain patients with patients from other treatment sectors with respect to sociodemographic, pain-related and psychological characteristics has not yet been the subject of systematic analyses. The project core documentation and quality assurance in pain therapy (KEDOQ-pain) of the German Pain Society (Deutsche Schmerzgesellschaft e.V.) makes this comparison possible. This second analysis of the available KEDOQ data was intended to show how patients receiving day care treatment can be characterized using the core data set and whether and to what extent they differ from patients receiving outpatient or inpatient treatment. This is a continuation of the first publication, which showed remarkably small differences between outpatients and inpatients but did not include day care patients.The KEDOQ-pain data from 25 centers with a total of 8953 patients were evaluated. Patients had completed the German pain questionnaire (DSF) between January 2012 and March 2017 and received day care (n = 1264), outpatient (n = 4082) or inpatient (n = 3607) pain therapy treatment. Sociodemographic, pain-related and psychometric data of the DSF reported by patients were evaluated as well as physician information on the pain chronification stage and pain localization. The evaluation was descriptive and compared groups using univariate and multivariate procedures.Day care treated patients were significantly younger, had a higher level of education, were more frequently employed, reported higher impairment values and showed a higher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described a shorter pain duration as well as worse habitual well-being (Marburg questionnaire on habitual well-being, MFHW). These predictors explained roughly half of the variance in the prediction of the day care treatment setting. The comparison of outpatients and inpatients showed significant group differences for some variables; however, the effects were very small.The evaluations suggest that pain therapy day care facilities treat a special group of pain patients that significantly differ from patients in other treatment sectors. Cautious conclusions are drawn regarding the systematic allocation of patients to care appropriate to their treatment needs.

[Realtime video consultations by psychotherapists in times of the COVID-19 pandemic]

Wegen der durch die „corona virus disease 2019“ (COVID-19) ausgelösten Pandemie und den resultierenden Beeinträchtigungen persönlicher (d. h. von Angesicht zu Angesicht stattfindender) Behandlung haben Videokonsultationen in der Erbringung von Gesundheitsleistungen massiv an Bedeutung zugenommen. Die meisten Psychotherapeuten haben allerdings bis dato wenig praktische Erfahrung in der Durchführung von Videokonsultationen, nicht zuletzt auch aufgrund bisher eingeschränkter Möglichkeiten zur Abrechnung mit den Kostenträgern. Der vorliegende Beitrag stellt (1) eine Übersicht über die Wirksamkeit per Videokonsultation durchgeführter psychotherapeutischer Interventionen bei depressiven und Angststörungen, (2) Empfehlungen zur spezifischen Gestaltung des Behandlungsrahmens sowie (3) erste Erfahrungen von Patienten und Psychotherapeuten aus einer deutschen Machbarkeitsstudie sowie mit dem Routineangebot im Krankenhaus während der COVID-19-Pandemie vor.

Practical factors determining adolescent substance use treatment settings: Results from four online stakeholder panels

Practical factors can significantly influence the setting, or level of care, where an adolescent receives substance use treatment. This study aimed to identify practical factors that stakeholders find most critical to consider when planning adolescent substance use treatment. We conducted online panels with four stakeholder groups: providers, policymakers, researchers, and parents. Stakeholders nominated, rated, and commented on the importance of 10 practical factors that could influence treatment setting decisions. We assessed consensus on the rated importance of practical factors using the RAND/UCLA Appropriateness Method. We thematically analyzed stakeholders comments to explain how they differentiated relative importance. 153 stakeholders (66 providers, 38 policymakers, 27 researchers, and 22 parents) identified continuity of care, coordination of care across service sectors, and quality of care as the practical factors of highest importance. Participants rated higher the practical factors they perceived to (1) trump clinical appropriateness as the reason for placing an adolescent in a given setting, (2) steer adolescents toward specific settings, or (3) steer an adolescent away from specific settings. Conversely, participants rated lower the practical factors they perceived (1) applicable to clinical intervention rather than treatment setting, (2) unrelated to initial recommendations, (3) relevant to any setting, or (4) applicable only to certain contexts and sub-populations. These findings help elucidate why stakeholders view certain practical factors as critical to consider in actual decisions about substance use treatment settings for adolescents. Future research should investigate how to incorporate these practical factors alongside clinical needs and treatment goals in placement criteria and treatment matching.

[Pain therapy in Germany - what is the difference between initial outpatient and inpatient treatment? : Assessment based on the KEDOQ pain dataset]

A comparison of chronic pain patients in outpatient and inpatient treatment settings regarding pain-related and psychological characteristics, has not yet been systematically analyzed. The core documentation and quality assurance in pain therapy (KEDOQ-Schmerz) is a quality assurance system for documentation and quality management of pain therapy in different treatment settings. The system was initiated by the German Pain Society. We used KEDOQ-Schmerz data to describe differences between patients being treated in outpatient and inpatient settings with respect to social, pain-related and psychological factors. In total, the set of KEDOQ-Schmerz data analyzed included information from 4705 patients (from 13 clinics) collected between January 2012 and April 2016. Patients received either outpatient (n = 2682) or inpatient (n = 2023) treatment. The data analyzed comprised sociodemographic, pain-related and psychological data collected through the German Pain Questionnaire (DSF) at the beginning of treatment as well as information about pain chronification and pain localization provided by practitioners. The statistical analysis was carried out by descriptive and comparative data analysis using univariate and multivariate statistical methods. Patients with inpatient treatment were significantly older, more often female and more often had multiple pain localizations. They described stronger pain intensity and more frequently had a higher Mainz Pain Staging System (MPSS) score of pain chronification. They described a significantly poorer physical and mental health-related quality of life in the short form (SF-12) health survey, had significantly higher depression, anxiety and stress values (DASS) and a poorer habitual well-being in the Marburg questionnaire on habitual well-being (MFHW). Significant group differences had only small effect sizes. Even though most predictors for the inpatient treatment setting in multivariate analysis were significant, in total they explained less than 5% of the variance. The results indicate that pain therapy in specialized pain settings more and more has to manage patients with higher pain chronification, higher pain-related stress and previous therapy experience. The differences in patient characteristics between treatment settings are mostly clinically unimportant. Differences in clinical features do not declare the allocation to one treatment setting or the other.

The Clinical Inadequacy of the Placebo Model and the Development of an Alternative Conceptual Framework

Placebo effects are often attributed to clinical interactions and contextual factors that affect expectations of the patient about the treatment and result in symptom changes. The prevailing conceptualization consists of an undifferentiated placebo response that needs to be minimized in controlled investigations and maximized in clinical practice. However, treatment outcome is the cumulative result of the interaction of several classes of variables with a selected treatment: living conditions (housing, nutrition, work environment, social support), patient characteristics (age, sex, genetics, general health conditions, personality, well-being), illness features and previous therapeutic experience, self-management, and treatment setting (physician's attitude and attention, illness behavior). Such variables may be therapeutic or countertherapeutic, and are unlikely to be simply additive. In certain patients their interactive combination may lead to clinical improvement, whereas in other cases it may produce no effect, and, in a third group, it may lead to worsening of the condition. Maximizing patients' expectations does not necessarily result in sustained effects and, in due course, may actually lead to worsening of the condition (violation of expectations). In this paper, we outline a multifactorial conceptual model that may have implications for the design of clinical trials as well as for clinical practice, with special reference to psychopharmacology and psychotherapy. The effects of drug treatment may be potentiated by specific nonpharmacological treatment strategies, and this synergism may disclose significant differences against placebo. Medical outcomes may be unsatisfactory not because technical interventions are missing, but because our conceptual models and thinking are inadequate.

[Substance abuse detection in substitution therapy : Oral fluid versus urine screening]

BACKGROUND

A patient's health in an opioid maintenance program is potentially endangered due to concurrent consumption of drugs. Therefore, the German Medical Association requests evidence of compliant substitute intake while type and frequency of drug screening is chosen by the physician. This study comparatively assessed the feasibility and potential advantage of oral fluid drug testing versus urine screening in day-to-day practice.

METHODS

Urine and oral fluid-samples of a randomly chosen third of a total of 361 patients, treated in four different practices in a major German city, were tested. The detection rates were compared bivariate and the illicit substance intake of subgroups were analysed. Additionally, patients' and employees' satisfaction with the test procedures were assessed.

RESULTS

A total of 117 paired urine and oral fluid samples were considered for this study. A dual sample collection was not obtainable with 29 patients due to insufficient sample volume or refusal. Other than methadone or buprenorphine, 155 substances were found in urine samples, whereas only 82 other substances were detected in oral fluids. Significant differences existed within substance groups with THC being positive in 50 (42.7%) urine samples and only three (2.6%) positive oral fluid samples (p < 0.0001) and with benzodiazepines with 41 (35%) positive urine and 28 (23.9%) positive oral fluid samples (p < 0.0001), respectively. In total 75.2% of the urine samples were positive for concurrent drug consumption. Employees and patients did not prefer one test type over the other.

CONCLUSION

The confirmation of concurrent drug intake in maintenance setting is generally possible by the use of oral fluid, but inferior to urine screening.