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Kilbourne AM, Welsh D, McCarthy JF, Post EP, Blow FC. Quality of care for cardiovascular disease-related conditions in patients with and without mental disorders. J Gen Intern Med 2008; 23:1628-33. [PMID: 18626722 PMCID: PMC2533391 DOI: 10.1007/s11606-008-0720-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 02/27/2008] [Accepted: 06/25/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We compared the quality of care for cardiovascular disease (CVD)-related risk factors for patients diagnosed with and without mental disorders. METHODS We identified all patients included in the fiscal year 2005 (FY05) VA External Peer Review Program's (EPRP) national random sample of chart reviews for assessing quality of care for CVD-related conditions. Using the VA's National Psychosis Registry and the National Registry for Depression, we assessed whether patients had received diagnoses of serious mental illness (schizophrenia, bipolar disorder, or other psychoses) or depression during FY05. Using multivariable logistic regression and generalized estimating equation analyses, we assessed patient and facility factors associated with receipt of guideline concordant care for hypertension (total N = 24,016), hyperlipidemia (N = 46,430), and diabetes (N = 10,943). RESULTS Overall, 70% had good blood pressure control, 90% received a cholesterol (hyperlipidemia) screen, 77% received a retinal exam for diabetes, and 63% received recommended renal tests for diabetes. After adjustment, compared to patients without SMI or depression, patients with SMI were less likely to be assessed for CVD risk factors, notably hyperlipidemia (OR = 0.58; p < 0.001), and less likely to receive recommended follow-up assessments for diabetes: foot exam (OR = 0.68; p < 0.001), retinal exam (OR = 0.65; p < 0.001), or renal testing (OR = 0.64; p < 0.001). Patients with depression were also significantly less likely to receive adequate quality of care compared to non-psychiatric patients, although effects were smaller than those observed for patients with SMI. CONCLUSIONS Quality of care for major chronic conditions associated with premature CVD-related mortality is suboptimal for VA patients with SMI, especially for procedures requiring care by a specialist.
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Kilbourne AM, Post EP, Nossek A, Sonel E, Drill LJ, Cooley S, Bauer MS. Service delivery in older patients with bipolar disorder: a review and development of a medical care model. Bipolar Disord 2008; 10:672-83. [PMID: 18837861 DOI: 10.1111/j.1399-5618.2008.00602.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Medical comorbidities, especially cardiovascular disease (CVD), occur disproportionately in older patients with bipolar disorder. We describe the development, implementation, and feasibility/tolerability results of a manual-based medical care model (BCM) designed to improve medical outcomes in older patients with bipolar disorder. METHODS The BCM consisted of (i) self-management sessions focused on bipolar disorder symptom control, healthy habits, and provider engagement, (ii) telephone care management to coordinate care and reinforce self-management goals, and (iii) guideline dissemination focused on medical issues in bipolar disorder. Older patients with bipolar disorder and a CVD-related risk factor (n = 58) were consented, enrolled, and randomized to receive BCM or usual care. RESULTS Baseline assessment (mean age = 55, 9% female, 9% African American) revealed a vulnerable population: 21% were substance users, 31% relied on public transportation, and 22% reported problems accessing medical care. Evaluation of BCM feasibility revealed high overall patient satisfaction with the intervention, high fidelity (e.g., majority of self-management sessions and follow-up contacts completed), and good tolerability (dropout rate <5%). Use of telephone contacts may have mitigated barriers to medical care (e.g., transportation). CONCLUSIONS The BCM is a feasible model for older, medically ill patients with bipolar disorder, and could be an alternative to more costly treatment models that involve co-location and/or additional hiring of medical providers in mental health clinics. Future research directions pertinent to the development of the BCM and other medical care models for older patients with bipolar disorder include assessment of their long-term effects on physical health and their cost-effectiveness across different treatment settings.
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Gold KJ, Kilbourne AM, Valenstein M. Primary care of patients with serious mental illness: your chance to make a difference. THE JOURNAL OF FAMILY PRACTICE 2008; 57:515-525. [PMID: 18687227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Gold KJ, Kilbourne AM, Valenstein M. Improving care for patients with serious mental illness. Am Fam Physician 2008; 78:314-315. [PMID: 18711944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Kilbourne AM, Post EP, Nossek A, Drill L, Cooley S, Bauer MS. Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial. Psychiatr Serv 2008; 59:760-8. [PMID: 18586993 DOI: 10.1176/ps.2008.59.7.760] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Comorbid medical conditions, notably cardiovascular disease, occur disproportionately among persons with bipolar disorder; yet the quality and outcomes of medical care for these individuals are suboptimal. This pilot study examined a bipolar disorder medical care model (BCM) and determined whether, compared with usual care, individuals randomly assigned to receive BCM care had improved medical and psychiatric outcomes. METHODS Persons with bipolar disorder and cardiovascular disease-related risk factors were recruited from a large Department of Veterans Affairs mental health facility and randomly assigned to receive BCM or usual care. BCM care consisted of four self-management sessions on bipolar disorder symptom control strategies, education and behavioral change related to cardiovascular disease risk factors, and promotion of provider engagement. Primary outcomes were physical and mental health-related quality of life; secondary outcomes included functioning and bipolar symptoms. RESULTS Fifty-eight persons participated. Twenty-seven received BCM care, and 31 received usual care. The mean+/-SD age was 55+/-8 years, 9% were female, 90% were white, and 10% were African American. Repeated-measures analysis was used, and significant differences were observed between the two groups in change in scores from baseline to six months for the 12-Item Short-Form Health Survey (SF-12) subscale for physical health (t=2.01, df=173, p=.04), indicating that the usual care group experienced a decline in physical health over the study period. Change in SF-12 scores also indicated that compared with the usual care group, the BCM group showed improvements in mental health-related quality of life over the six-month study period; however, this finding was not significant. CONCLUSIONS Compared with usual care, BCM care may have slowed the decline in physical health-related quality of life. Further studies are needed to determine whether BCM care leads to long-term positive changes in physical and mental health-related quality of life and reduced risk of cardiovascular disease among persons with bipolar disorder.
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Teh CF, Kilbourne AM, McCarthy JF, Welsh D, Blow FC. Gender differences in health-related quality of life for veterans with serious mental illness. Psychiatr Serv 2008; 59:663-9. [PMID: 18511587 DOI: 10.1176/ps.2008.59.6.663] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study assessed gender differences in health-related quality of life (HRQOL) in a national sample of veterans with serious mental illness. METHODS Data were analyzed from the Large Health Survey of Veterans, which was mailed to a national random sample of veterans in 1999. The linear and logistic multiple regression analyses included 18,017 veterans with schizophrenia, schizoaffective disorder, or bipolar disorder who completed the survey. HRQOL was measured by using the various subscales of the 36-Item Short Form of the Medical Outcomes Study (MOS SF-36) (mental component summary, physical component summary, and activities of daily living) and by questions assessing self-perceptions of health status. RESULTS The sample was 7.3% female, 75.7% white, and 83.8% unemployed. Mean+/-SD age was 54.3+/-12.2 years. After the analysis adjusted for sociodemographic characteristics, health status, and other variables, compared with male veterans, female veterans with serious mental illness had lower scores on the SF-36 physical component summary (indicating worse symptoms), were more likely to report that they were limited "a lot" in activities of daily living, and had more pain. However, female respondents were more likely to have a positive outlook on their health. CONCLUSIONS Among veterans who received a diagnosis of serious mental illness from providers of the Department of Veterans Affairs, women reported substantially poorer HRQOL than men across several domains but women reported better self-perceived health. Attention to the particular needs of female veterans with serious mental illness is imperative as the numbers of female veterans continue to increase.
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Kilbourne AM, Lasky E, Pincus HA, Good CB, Cooley S, Basavaraju A, Greenwald D, Fine MJ, Bauer MS. The continuous improvement for veterans in care: Mood Disorders (civic-md) Study, a VA-academic partnership. Psychiatr Serv 2008; 59:483-5. [PMID: 18451002 DOI: 10.1176/ps.2008.59.5.483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Department of Veterans Affairs (VA) provides an ideal opportunity to conduct mental health services research among vulnerable populations, given its extensive data sources, disproportionate number of vulnerable patients (older, often with comorbidities), and quality improvement mission. Although VA facilities are often affiliated with universities, successful VA-academic research partnerships are sometimes elusive. The Continuous Improvement for Veterans in Care: Mood Disorders (CIVIC-MD) study was a partnership with a VA facility that had not been engaged in mood disorders research. This column describes how the partnership formed, key elements of its success, and challenges and opportunities to inform future research partnerships.
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Zeber JE, Copeland LA, Good CB, Fine MJ, Bauer MS, Kilbourne AM. Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder. J Affect Disord 2008; 107:53-62. [PMID: 17822779 DOI: 10.1016/j.jad.2007.07.026] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 07/25/2007] [Accepted: 07/31/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite the dissemination of practice guidelines for bipolar disorder, outcomes remain suboptimal, largely due to poor treatment adherence. The episodic nature of bipolar disorder disrupts appropriate patient-provider dynamics, interfering with appropriate care. Maintaining a beneficial therapeutic alliance with providers is one important strategy for improving adherence. We examine the association between adherence and therapeutic environment perceptions among veterans with bipolar disorder. METHODS Participants were recruited from the Continuous Improvement for Veterans in Care--Mood Disorders (CIVIC-MD) study (N=435). Individual items and a summary score from the Health Care Climate Questionnaire (HCCQ) for bipolar disorder solicited patient evaluations of their therapeutic environment. Multivariable logistic analyses examined the association between therapeutic alliance and two measures of adherence (missed medication days and intrapersonal barriers), adjusting for relevant patient characteristics. RESULTS Adherence difficulty was reported on both measures, with substantial differences between perceived barriers and actual medication behavior. Significantly fewer minority veterans endorsed good adherence than white patients (59% versus 77%), although no ethnic differences were noted in therapeutic environment perceptions. Multivariable results indicated that positive therapeutic alliance was associated with better adherence (HCCQ effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress". LIMITATIONS Generalizability from observational study; adherence defined by cross-sectional patient self-report. CONCLUSIONS The observed association between medication adherence and therapeutic alliance with bipolar treatment supports intervention efforts to strengthen the patient-provider relationship, a bond likely to yield positive clinical outcomes.
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Copeland LA, Zeber JE, Salloum IM, Pincus HA, Fine MJ, Kilbourne AM. Treatment adherence and illness insight in veterans with bipolar disorder. J Nerv Ment Dis 2008; 196:16-21. [PMID: 18195637 DOI: 10.1097/nmd.0b013e318160ea00] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Insight into the perceived value of psychotherapy and pharmacological treatment may improve adherence to medication regimens among patients with bipolar disorder, because patients are more likely to take medication they believe will make them better. We conducted a cross-sectional survey of patients recruited into the Continuous Improvement for Veterans in Care-Mood Disorders (CIVIC-MD; July 2004-July 2006), assessing therapeutic insight and 2 measures of medication adherence: the Morisky scale of intrapersonal barriers and missing any doses the previous 4 days. Among 435 patients with bipolar disorder, 27% had poor adherence based on missed dose and 46% had poor adherence based on the Morisky. In multivariable models, greater insight into medication was negatively associated with both measures of poor adherence. Odds of poor adherence increased for women, African Americans, mania, and hazardous drinking. The association of mutable factors-hazardous drinking, manic symptoms, and insight-could represent an opportunity to improve adherence.
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Kilbourne AM, Neumann MS, Pincus HA, Bauer MS, Stall R. Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implement Sci 2007; 2:42. [PMID: 18067681 PMCID: PMC2248206 DOI: 10.1186/1748-5908-2-42] [Citation(s) in RCA: 383] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 12/09/2007] [Indexed: 11/11/2022] Open
Abstract
Background We describe the use of a conceptual framework and implementation protocol to prepare effective health services interventions for implementation in community-based (i.e., non-academic-affiliated) settings. Methods The framework is based on the experiences of the U.S. Centers for Disease Control and Prevention (CDC) Replicating Effective Programs (REP) project, which has been at the forefront of developing systematic and effective strategies to prepare HIV interventions for dissemination. This article describes the REP framework, and how it can be applied to implement clinical and health services interventions in community-based organizations. Results REP consists of four phases: pre-conditions (e.g., identifying need, target population, and suitable intervention), pre-implementation (e.g., intervention packaging and community input), implementation (e.g., package dissemination, training, technical assistance, and evaluation), and maintenance and evolution (e.g., preparing the intervention for sustainability). Key components of REP, including intervention packaging, training, technical assistance, and fidelity assessment are crucial to the implementation of effective interventions in health care. Conclusion REP is a well-suited framework for implementing health care interventions, as it specifies steps needed to maximize fidelity while allowing opportunities for flexibility (i.e., local customizing) to maximize transferability. Strategies that foster the sustainability of REP as a tool to implement effective health care interventions need to be developed and tested.
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Sevick MA, Trauth JM, Ling BS, Anderson RT, Piatt GA, Kilbourne AM, Goodman RM. Patients with Complex Chronic Diseases: perspectives on supporting self-management. J Gen Intern Med 2007; 22 Suppl 3:438-44. [PMID: 18026814 PMCID: PMC2150604 DOI: 10.1007/s11606-007-0316-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A Complex Chronic Disease (CCD) is a condition involving multiple morbidities that requires the attention of multiple health care providers or facilities and possibly community (home)-based care. A patient with CCD presents to the health care system with unique needs, disabilities, or functional limitations. The literature on how to best support self-management efforts in those with CCD is lacking. With this paper, the authors present the case of an individual with diabetes and end-stage renal disease who is having difficulty with self-management. The case is discussed in terms of intervention effectiveness in the areas of prevention, addiction, and self-management of single diseases. Implications for research are discussed.
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Altshuler L, Tekell J, Biswas K, Kilbourne AM, Evans D, Tang D, Bauer MS. Executive function and employment status among veterans with bipolar disorder. Psychiatr Serv 2007; 58:1441-7. [PMID: 17978254 DOI: 10.1176/ps.2007.58.11.1441] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study assessed the relationship between neurocognitive function (measured by the Executive Interview [EXIT]) and occupational role function (measured by employment status) in a large cohort of Veterans Affairs patients with bipolar disorder. METHODS A total of 213 patients in a national bipolar disorder intervention study (Department of Veterans Affairs Cooperative Study 430) were dichotomized into two groups--employed (N=91) and unemployed (N=122)--on the basis of responses to a semistructured interview regarding past-year work history. Bivariate analysis was used to assess whether any participant characteristics and course-of-illness variables were significantly different between the employed and unemployed groups and thus could confound results. A stepwise logistic regression was then performed to investigate the association between neurocognitive function and employment status by using the significant demographic and course-of-illness variables as covariates. RESULTS There were significant differences in EXIT scores between the employed and unemployed groups, with the unemployed group showing greater executive impairment. Lifetime psychiatric hospitalizations and number of psychotropic medications prescribed had significant associations with employment status. When these variables were entered into a regression analysis, employment status could still be explained by executive functioning. CONCLUSIONS This study found that poor executive function may be associated with poor work adjustment (unemployment) among patients with bipolar disorder. The etiology of this relationship and the contributory role of the prior number of hospitalizations and number of psychotropic medications to executive function remain to be further evaluated.
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Kilbourne AM, Post EP, Bauer MS, Zeber JE, Copeland LA, Good CB, Pincus HA. Therapeutic drug and cardiovascular disease risk monitoring in patients with bipolar disorder. J Affect Disord 2007; 102:145-51. [PMID: 17276514 DOI: 10.1016/j.jad.2007.01.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Revised: 12/21/2006] [Accepted: 01/04/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We assessed whether patients with bipolar disorder received serum drug level and toxicity monitoring for mood stabilizers and assessment of cardiovascular disease (CVD)-related risk factors attributed to atypical antipsychotic medications. METHODS A population-based study of individuals with bipolar disorder was conducted between July 2004 and July 2006. Based on American Psychiatric and American Diabetes Association guidelines, we assessed whether patients received recommended drug level and toxicity monitoring tests on or within 6 months for mood stabilizers, and lipid and glucose tests for atypical antipsychotics. Multivariable regression was used to determine the patient factors associated with receipt of lab tests. RESULTS Of the 435 patients (mean age=49 years, 14.3% female, 22.8% nonwhite), 60.3% were currently prescribed mood stabilizers and 65.5% were prescribed atypical antipsychotics. Overall, 39.7% received a serum drug level for mood stabilizers, 38.8% received a thyroid function test for lithium, and the majority (71.4%-75.9%) received complete blood counts and hepatic function tests for valproate or carbamazepine. About half of patients prescribed atypical antipsychotics received cholesterol counts (49.6%), and 68.7% received serum glucose levels. After adjusting for patient factors, women prescribed atypical antipsychotics were less likely than men to receive cholesterol counts (OR=0.43; p<0.05). LIMITATIONS Single-site retrospective study and a relatively short observation period. CONCLUSIONS About half of patients received recommended lab tests for mood stabilizers and atypical antipsychotics. Additional research regarding whether the receipt of these lab tests is associated with improved outcomes will inform efforts to improve quality of care related to drug toxicities and CVD risk factors in patients with bipolar disorder.
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Kilbourne AM, Brar JS, Drayer RA, Xu X, Post EP. Cardiovascular Disease and Metabolic Risk Factors in Male Patients With Schizophrenia, Schizoaffective Disorder, and Bipolar Disorder. PSYCHOSOMATICS 2007; 48:412-7. [PMID: 17878500 DOI: 10.1176/appi.psy.48.5.412] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The authors determined whether diagnoses of cardiovascular disease (CVD) and CVD-related conditions differed by psychiatric diagnosis among male Veterans Administration patients from the mid-Atlantic region. Among 7,529 patients (mean age: 54.5 years), the prevalence of diagnoses ranged from 3.6% (stroke) to 35.4% (hypertension). Compared with schizophrenia patients, those with bipolar disorder were 19% more likely to have diabetes, 44% more likely to have coronary artery disease, and 18% more likely to have dyslipidemia, after adjustment. Clinical suspicion for CVD-related conditions, as well as risk-modification strategies, in patients with serious mental illness should incorporate differences in prevalence across specific psychiatric diagnoses.
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Kilbourne AM, Rofey DL, McCarthy JF, Post EP, Welsh D, Blow FC. Nutrition and exercise behavior among patients with bipolar disorder. Bipolar Disord 2007; 9:443-52. [PMID: 17680914 DOI: 10.1111/j.1399-5618.2007.00386.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES There have been few comprehensive studies of nutrition and exercise behaviors among patients with bipolar disorder (BPD). Based on a national sample of patients receiving care in the Veterans Affairs (VA) health care system, we compared nutrition and exercise behaviors among individuals diagnosed with BPD, others diagnosed with schizophrenia, and others who did not receive diagnoses of serious mental illness (SMI). METHODS We conducted a cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in fiscal year (FY) 1999 and who either received a diagnosis of BPD (n = 2,032) or schizophrenia (n = 1,895), or were included in a random sample of non-SMI VA patients (n = 3,065). We compared nutrition and exercise behaviors using multivariable logistic regression, controlling for patient socio-economic and clinical factors, and adjusting for patients clustered by site using generalized estimating equations. RESULTS Patients with BPD were more likely to report poor exercise habits, including infrequent walking (odds ratio, OR = 1.33, p < 0.001) or strength exercises (OR = 1.28, p < 0.001) than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than two daily meals (OR = 1.32, p < 0.001) and having difficulty obtaining or cooking food (OR = 1.48, p < 0.001). Patients with BPD were also more likely to report having gained >or=10 pounds in the past 6 months (OR = 1.59, p < 0.001) and were the least likely to report that their health care provider discussed their eating habits (OR = 0.84, p < 0.05) or physical activity (OR = 0.81, p < 0.01). CONCLUSIONS Greater efforts are needed to reduce the risk of poor nutrition and exercise habits among patients diagnosed with BPD.
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Kilbourne AM, McCarthy JF, Post EP, Welsh D, Blow FC. Social support among veterans with serious mental illness. Soc Psychiatry Psychiatr Epidemiol 2007; 42:639-46. [PMID: 17520160 DOI: 10.1007/s00127-007-0212-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND We determined whether patients with serious mental illness were more likely to report low social support than those without serious mental illness. METHOD We conducted a national, cross-sectional study of VA patients in Fiscal Year 1999 who were diagnosed with a serious mental illness, as well as a random sample of VA patients without a diagnosis of serious mental illness (N = 8,547) from the National Psychosis Registry who also completed the VA's Large Health Survey of Veteran Enrollees (LHSV) 9-item questionnaire on social support. Using generalized estimating equations; we assessed patient's likelihood of reporting low social support, while controlling for patient socio-economic and clinical factors. RESULTS In multivariable models adjusting for patient factors, patients with serious mental illness were more likely to report low instrumental support, e.g., having no one to help with chores (OR = 1.41, p < 0.001) and low emotional support, e.g., having no one to relax with (OR = 2.05, p < 0.001). CONCLUSIONS Patients diagnosed with serious mental illness reported low social support across different dimensions. Recovery-oriented services for persons with serious mental illness should focus on improving and sustaining emotional and instrumental supports for this vulnerable population.
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Kilbourne AM, McCarthy JF, Post EP, Welsh D, Pincus HA, Bauer MS, Blow FC. Access to and satisfaction with care comparing patients with and without serious mental illness. Int J Psychiatry Med 2007; 36:383-99. [PMID: 17407993 DOI: 10.2190/04xr-3107-4004-4670] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We compared perceived access to and satisfaction with health care between patients diagnosed with serious mental illness (SMI: schizophrenia or bipolar disorder) and among those with no SMI diagnosis. METHOD We conducted a national, cross-sectional study of VA patients in Fiscal Year (FY) 1999 (N = 7,187) who completed the VA's Large Health Survey of Veteran Enrollees (LHSV) section on access and satisfaction and either received a diagnosis of schizophrenia or bipolar disorder, or did not and were randomly selected from the general non-SMI VA patient population (non-SMI group). We compared the probability of perceived poor access and dissatisfaction using multivariable logistic regression adjusting for patient covariates. RESULTS Compared to non-SMI patients, patients diagnosed with bipolar disorder were more likely to report difficulty in receiving care they needed (adjusted OR = 1.36,p < .05) or seeing a specialist (adjusted OR = 1.44, p < .001). Patients diagnosed with schizophrenia were more likely to report dissatisfaction, including thoroughness by their provider (adjusted OR = 1.37, p < .001) and the provider's explanation of problems (adjusted OR = 1.54, p < .001) compared to non-SMI patients. CONCLUSIONS Patients diagnosed with bipolar disorder reported greater problems with access to health care, while those diagnosed with schizophrenia were less satisfied with the process of care.
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Zeber JE, McCarthy JF, Bauer MS, Kilbourne AM. Datapoints: self-reported access to general medical and psychiatric care among veterans with bipolar disorder. Psychiatr Serv 2007; 58:740. [PMID: 17535932 DOI: 10.1176/ps.2007.58.6.740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kilbourne AM, Valenstein M, Bauer MS. The research-to-practice gap in mood disorders: a role for the U.S. Department of Veterans Affairs. J Clin Psychiatry 2007; 68:502-4. [PMID: 17474803 DOI: 10.4088/jcp.v68n0402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kilbourne AM, Copeland LA, Zeber JE, Bauer MS, Lasky E, Good CB. Determinants of complementary and alternative medicine use by patients with bipolar disorder. PSYCHOPHARMACOLOGY BULLETIN 2007; 40:104-115. [PMID: 18007572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES We determined the prevalence and correlates of complementary and alternative medicine (CAM) use among patients with bipolar disorder. METHODS Patients with bipolar disorder recruited from a large urban mental health facility from 2004 to 2006 completed a baseline questionnaire on CAM use, demographics, treatment perspectives, and behaviors. Additional data on current medications and clinical features were ascertained via chart review. Multivariable logistic regression was used to determine the patient sociodemographic, clinical, and treatment factors associated with use of different CAM practices. RESULTS Of 435 patients, the mean age was 49 years; 77% were white, 13% were black, and 10% other race/ethnicity. Patients reported a wide range of CAM use, including prayer/spiritual healing (54%), meditation (53%), vitamins or herbs (50%), and weight loss supplements (22%). Multivariable analyses controlling for sociodemographic, clinical, and treatment factors revealed that patients of other racial/ethnic groups (other than whites or Blacks), those diagnosed with bipolar spectrum disorders (other than bipolar I disorder), and those prescribed anticonvulsants (eg, valproic acid, carbamazepine), or atypical antipsychotics were most likely to use CAM. CONCLUSIONS A substantial number of patients diagnosed with bipolar disorder is using CAM. CAM use may be popular among patients with this illness because conventional pharmacotherapy for managing bipolar symptoms can also disrupt quality of life. Mental health providers should be aware of CAM use among patients with bipolar disorder and assess the potential impact of CAM use on treatment course.
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Kilbourne AM, Horvitz-Lennon M, Post EP, McCarthy JF, Cruz M, Welsh D, Blow FC. Oral Health in Veterans Affairs Patients Diagnosed with Serious Mental Illness. J Public Health Dent 2007; 67:42-8. [PMID: 17436978 DOI: 10.1111/j.1752-7325.2007.00007.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We evaluated patient and medication treatment factors associated with self-reported oral health status in patients diagnosed with serious mental illness (SMI) in a large, national sample of patients in the Veterans Affairs (VA) health system. METHODS 4,769 patients (mean age = 55, 7.8 percent women) were included from the VA's 1999 National Psychosis Registry (NPR) for whom the oral health information gathered by the VA's Large Health Survey of Veterans was available. Current (1999) psychotropic medication data were ascertained from the NPR. Multivariable logistic regression analyses were used to determine the patient factors (e.g., sociodemographic, enabling, and treatment factors) associated with poor or fair overall dental health, and with having tooth or mouth problems that made it difficult to eat. RESULTS While 61.0 percent of persons with SMI self-reported fair to poor dental health, 34.1 percent reported that oral health problems made it difficult for them to eat. Patients who were not employed, experiencing financial strain, who smoked, who were prescribed tricyclic antidepressants, or prescribed selective serotonin reuptake inhibitors were more likely to report poor or fair dental health. These variables were also associated with having tooth or mouth problems. CONCLUSIONS Suboptimal oral health was self-reported with substantial prevalence among patients with SMI, a problematic finding given its consequences for general health, social functioning, and quality of life. Greater efforts are needed to improve oral health outcomes among patients with SMI by facilitating access to dental care and addressing mutable factors such as smoking and medication side effects.
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Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 2006; 96:2113-21. [PMID: 17077411 PMCID: PMC1698151 DOI: 10.2105/ajph.2005.077628] [Citation(s) in RCA: 496] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We provide a framework for health services-related researchers, practitioners, and policy makers to guide future health disparities research in areas ranging from detecting differences in health and health care to understanding the determinants that underlie disparities to ultimately designing interventions that reduce and eliminate these disparities. To do this, we identified potential selection biases and definitions of vulnerable groups when detecting disparities. The key factors to understanding disparities were multilevel determinants of health disparities, including individual beliefs and preferences, effective patient-provider communication; and the organizational culture of the health care system. We encourage interventions that yield generalizable data on their effectiveness and that promote further engagement of communities, providers, and policymakers to ultimately enhance the application and the impact of health disparities research.
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Kilbourne AM, Salloum I, Dausey D, Cornelius JR, Conigliaro J, Xu X, Pincus HA. Quality of care for substance use disorders in patients with serious mental illness. J Subst Abuse Treat 2006; 30:73-7. [PMID: 16377454 DOI: 10.1016/j.jsat.2005.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 10/18/2005] [Accepted: 10/25/2005] [Indexed: 10/25/2022]
Abstract
We assessed the quality of care for substance use disorders (SUDs) among 8,083 patients diagnosed with serious mental illness from the VA mid-Atlantic region. Using data from the National Patient Care Database (2001-2002), we assessed the percentage of patients receiving a diagnosis of SUD, percentage beginning SUD treatment 14 days or earlier after diagnosis, and percentage receiving continued SUD care 30 days or less. Overall, 1,559 (19.3%) were diagnosed with an SUD. Of the 1,559, 966 (62.0%) initiated treatment and 847 (54.3%) received continued care. Although patients diagnosed with bipolar disorder were more likely to receive a diagnosis of SUD than those diagnosed with schizophrenia or schizoaffective disorder (22.7%, 18.9%, and 17.7%, respectively; chi(2) = 26.02, df = 2, p < .001), they were less likely to initiate (49.1%, 70.7%, and 68.6%, respectively; chi(2) = 59.29, df = 2, p < .001) or continue treatment (39.9%, 63.2%, and 62.2%, respectively; chi(2) = 72.25, df = 2, p <. 001). Greater efforts are needed to diagnose and treat SUDs in patients with serious mental illness, particularly for those with bipolar disorder.
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Kilbourne AM, McCarthy JF, Welsh D, Blow F. Recognition of co-occurring medical conditions among patients with serious mental illness. J Nerv Ment Dis 2006; 194:598-602. [PMID: 16909068 DOI: 10.1097/01.nmd.0000230637.21821.ec] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We determined whether patients with serious mental illness (SMI) were less likely than non-SMI to self-report having a medical condition that was recorded in their medical record. We included all patients from the VA National Psychosis Registry diagnosed with SMI and a random sample of non-SMI patients in fiscal year 1999 who completed the Large Health Survey of Veteran Enrollees (N = 35,837). Among patients with diagnoses for any of 11 conditions recorded in administrative data, we evaluated whether patients reported having that same condition in the survey, using multivariable logistic regression and generalized estimating equations. Among patients diagnosed with a given condition, those with SMI were less likely to report being told by providers that they had seven of the 11 conditions examined: heart disease (OR = 0.68, p < 0.001), arthritis (OR = 0.79, p < 0.001), cancer (OR = 0.69, p < 0.001), diabetes (OR = 0.79, p < 0.001), back pain (OR = 0.81, p < 0.001), congestive heart failure (OR = 0.71, p < 0.001), and hypertension (OR = 0.77, p < 0.001). Patients with SMI were less aware of co-occurring medical conditions.
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Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2006; 33:54-64. [PMID: 16215661 DOI: 10.1007/s10488-005-4236-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation's national program "Depression in Primary Care-Incentives Demonstrations." Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for health care practices and policy makers.
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