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Farrell SP, Mahone IH, Zerull LM, Guerlain S, Akan D, Hauenstein E, Schorling J. Electronic screening for mental health in rural primary care: implementation. Issues Ment Health Nurs 2009; 30:165-73. [PMID: 19291493 DOI: 10.1080/01612840802694411] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The goals of this study were to develop a computer-based electronic screening tool (eScreening) and determine the feasibility of implementing eScreening for rural users of primary care. This descriptive pilot adapted existing screening measures for depression and alcohol abuse to a portable computer-based format and examined the feasibility of its adoption and use. This was a three-step design using convenience samples for (1) a focus group with providers, (2) usability testing with selected rural patients using the computerized touch screen, and (3) implementing the touch screen platform with a small sample in primary care to determine feasibility. This paper reports on Phase III, which assessed consumer response to eScreening.
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Affiliation(s)
- Sarah P Farrell
- School of Nursing, University of Virginia, Charlottesville, Virginia 22908-0782, USA
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2
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Hermann RC, Mattke S, Somekh D, Silfverhielm H, Goldner E, Glover G, Pirkis J, Mainz J, Chan JA. Quality indicators for international benchmarking of mental health care. Int J Qual Health Care 2006; 18 Suppl 1:31-8. [PMID: 16954514 DOI: 10.1093/intqhc/mzl025] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify quality measures for international benchmarking of mental health care that assess important processes and outcomes of care, are scientifically sound, and are feasible to construct from preexisting data. DESIGN An international expert panel employed a consensus development process to select important, sound, and feasible measures based on a framework that balances these priorities with the additional goal of assessing the breadth of mental health care across key dimensions. PARTICIPANTS Six countries and one international organization nominated seven panelists consisting of mental health administrators, clinicians, and services researchers with expertise in quality of care, epidemiology, public health, and public policy. Measures. Measures with a final median score of at least 7.0 for both importance and soundness, and data availability rated as 'possible' or better in at least half of participating countries, were included in the final set. Measures with median scores </=3.0 or data availability rated as 'unlikely' were excluded. Measures with intermediate scores were subject to further discussion by the panel, leading to their adoption or rejection on a case-by-case basis. RESULTS From an initial set of 134 candidate measures, the panel identified 12 measures that achieved moderate to high scores on desired attributes. CONCLUSIONS Although limited, the proposed measure set provides a starting point for international benchmarking of mental health care. It addresses known quality problems and achieves some breadth across diverse dimensions of mental health care.
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Affiliation(s)
- Richard C Hermann
- Tufts-New England Medical Center, Center for Quality Assessment & Improvement in Mental Health (CQAIMH), 750 Washington Street, NEMC# 345, Boston, MA, 02111, USA. rhermann@cqaimh
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3
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Li H, Proctor E, Morrow-Howell N. Outpatient mental health service use by older adults after acute psychiatric hospitalization. J Behav Health Serv Res 2005; 32:74-84. [PMID: 15632799 DOI: 10.1007/bf02287329] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study described outpatient mental health service used by elderly patients discharged from acute inpatient psychiatric treatment for depression, assessed services barriers, and identified factors related to the use of outpatient mental health services. The sample consisted of 199 elderly patients discharged home from a geropsychiatric unit of an urban midwestern hospital. Multivariate logistic regression was used to identify factors associated with use of various mental health services. Almost three quarters of the elderly patients saw a psychiatrist within 6 weeks postdischarge, but few used other outpatient mental health services. The most frequently reported barriers to use included (1) cost of services, (2) personal belief that depression would improve on its own, and (3) lack of awareness of available services. The use of various outpatient services was differentially related to predisposing, need, and enabling factors. Female patients, those residing in rural areas, and those who wanted to solve their problems on their own were less likely to use outpatient mental health services. Patients who reported greater levels of functional impairment, resided in rural areas, and perceived that getting services required too much time were less likely to see a psychiatrist in the postacute period. African American patients were more likely than whites to use day treatment programs. This may be related to the fact that most day treatment centers were located in areas where the majority of residents were African Americans.
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Affiliation(s)
- Hong Li
- School of Social Work, University of Illinois at Urbana - Champaign, 1207 W Oregon, Urbana, IL 61801, USA.
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4
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Outpatient Mental Health Service Use by Older Adults After Acute Psychiatric Hospitalization. J Behav Health Serv Res 2005. [DOI: 10.1097/00075484-200501000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? 1998. Milbank Q 2005; 83:843-95. [PMID: 16279970 PMCID: PMC2690270 DOI: 10.1111/j.1468-0009.2005.00403.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Hermann RC, Palmer H, Leff S, Shwartz M, Provost S, Chan J, Chiu WT, Lagodmos G. Achieving consensus across diverse stakeholders on quality measures for mental healthcare. Med Care 2004; 42:1246-53. [PMID: 15550805 DOI: 10.1097/00005650-200412000-00012] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Quality-improvement efforts are hindered by a lack of consensus on meaningful and feasible measures of care. The objective of this study was to develop a core set of quality measures for mental health and substance-related care that are meaningful to stakeholders, feasible to implement, and broadly representative of diverse dimensions of the mental health system. METHOD A 12-member panel of stakeholders from national organizations evaluated 116 process measures in a 2-stage modified Delphi consensus development process. Drawing on a conceptual framework and literature review, panelists rated each measure on 7 domains using a 9-point scale (1 = best). Measures were then mapped to a framework of system dimensions to identify a core set with the highest ratings for system characteristics within each dimension. RESULTS Twenty-eight measures were identified assessing treatment (12), access (2), assessment (2), continuity (4), coordination (2), prevention (1), and safety (5). Overall, mean ratings for meaningfulness were: clinical importance 2.29; perceived gap between actual and optimal care 2.59; association between improved performance and outcome 2.61. For feasibility, mean ratings were clarity of specifications 3.39; acceptability of data collection burden 4.77; and adequacy of case mix adjustment 4.20. The measures address a range of treatment modalities, clinical settings, diagnostic categories, vulnerable populations, and other dimensions of mental healthcare. CONCLUSIONS A structured consensus process identified a core set of quality measures that are meaningful and feasible to multiple stakeholders, as well as broadly representative of the mental healthcare system. By yielding quantitative assessments of meaningfulness, feasibility and degree of consensus among stakeholders, these results can inform ongoing national efforts to adopt common quality measures for mental healthcare.
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Affiliation(s)
- Richard C Hermann
- Institute for Clinical Research and Health Policy Studies at Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Mulsant BH, Whyte E, Lenze EJ, Lotrich F, Karp JF, Pollock BG, Reynolds CF. Achieving long-term optimal outcomes in geriatric depression and anxiety. CNS Spectr 2003; 8:27-34. [PMID: 14978461 DOI: 10.1017/s1092852900008257] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.
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Affiliation(s)
- Benoit H Mulsant
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Asch SM, Kilbourne AM, Gifford AL, Burnam MA, Turner B, Shapiro MF, Bozzette SA. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med 2003; 18:450-60. [PMID: 12823652 PMCID: PMC1494868 DOI: 10.1046/j.1525-1497.2003.20938.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV. DESIGN Cross-sectional survey. PATIENTS/PARTICIPANTS National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data. MEASUREMENTS AND MAIN RESULTS We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers. CONCLUSIONS Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.
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Affiliation(s)
- Steven M Asch
- VA Los Angeles Healthcare System and UCLA Department of Medicine, Los Angeles, California 90073, USA
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Charbonneau A, Rosen AK, Ash AS, Owen RR, Kader B, Spiro A, Hankin C, Herz LR, Jo V Pugh M, Kazis L, Miller DR, Berlowitz DR. Measuring the quality of depression care in a large integrated health system. Med Care 2003; 41:669-80. [PMID: 12719691 DOI: 10.1097/01.mlr.0000062920.51692.b4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement. OBJECTIVES To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care. RESEARCH DESIGN This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care. SUBJECTS There were 12,678 patients eligible for depression care profiling. RESULTS Adequate dosage was identified in 90%; 45% of patients had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), black race, and treatment exclusively in primary care. CONCLUSIONS Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.
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Affiliation(s)
- Andrea Charbonneau
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts 01730, USA.
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Hughes CM, Lapane KL. The drive for quality care in US nursing homes in the era of the prospective payment system. Drugs Aging 2002; 19:623-31. [PMID: 12381233 DOI: 10.2165/00002512-200219090-00001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The quality of nursing home care has often given rise to concern from many interested stakeholders. In the US, this has led to the implementation of a major legislative framework in the form of the Nursing Home Reform Act, which sought to improve the quality of care through regulation and inspections. Research has shown that certain elements of care have improved but much remains to be done. Additional pressure is now being placed on the nursing home sector through the introduction of a prospective payment system (PPS), which sets limits on reimbursement for services for Medicare-covered stays. It has been proposed that this new system of payment may lead to difficulties in accessing nursing home care for patients who are deemed to be costly, and initial assessments suggest that patients are now carefully screened before being admitted to nursing homes. This may have major implications for patients who require multiple and expensive drug therapy and other interventions. Although the Nursing Home Reform Act seeks to drive forward the quality agenda in nursing home care, research is urgently required to evaluate the impact of the PPS which may force this healthcare sector to emphasise reducing costs at the expense of residents' needs.
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Affiliation(s)
- Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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Fischer EP, Marder SR, Smith GR, Owen RR, Rubenstein L, Hedrick SC, Curran GM. Quality Enhancement Research Initiative in Mental Health. Med Care 2000; 38:I70-81. [PMID: 10843272 DOI: 10.1097/00005650-200006001-00008] [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: 11/27/2022]
Abstract
The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.
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Affiliation(s)
- E P Fischer
- VA HSR&D Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System and the Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock 72114, USA
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Rojas-Fernandez C, Thomas VS, Carver D, Tonks R. Suboptimal use of antidepressants in the elderly: a population-based study in Nova Scotia. Clin Ther 1999; 21:1937-50. [PMID: 10890265 DOI: 10.1016/s0149-2918(00)86741-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This descriptive, retrospective, population-based study assessed patterns of antidepressant medication use in elderly patients in Nova Scotia during fiscal years 1993 through 1996. Individuals > or =65 years of age who were registered with Nova Scotia's Seniors Pharmacare program and filled a prescription for an antidepressant medication during the specified period were included in the study. We determined the number of individuals who filled > or =1 prescription for an antidepressant, the number whose prescription for an antidepressant could be matched with a diagnosis of depression in the physician's billing database, the number who used antidepressants that were judged inappropriate based on published criteria for medication prescribing in the elderly, the number who used a therapeutic antidepressant dose based on published dosing guidelines for the elderly, and the number who used antidepressants for > or =6 months. A total of 12,048, 12,317, and 13,419 individuals filled prescriptions for antidepressants during the 1993 to 1994, 1994 to 1995, and 1995 to 1996 fiscal years, respectively. In each fiscal year, approximately 70% had received a diagnosis of depression based on the International Classification of Diseases, Ninth Revision, Clinical Modification, making it likely that 70% of antidepressant users were receiving these drugs for a primary diagnosis of depression. The number of antidepressant prescriptions that were classified as inappropriate for use in the elderly was 67% in 1993 to 1994, 61% in 1994 to 1995, and 55% in 1995 to 1996. These decreases over time were statistically significant (P < 0.001). Among those using serotonin reuptake inhibitors, secondary tricyclic antidepressants, or tertiary tricyclic antidepressants, 79%, 45%, and 31%, respectively, appeared to be using therapeutic doses. Of 23,553 antidepressant treatment courses, 11,028 (47%) were for < or =180 days. During the study, a significant number of elderly individuals were prescribed antidepressant medications that are judged by expert consensus to be inappropriate for use in this population because of an unfavorable toxicity profile, although the number declined significantly from year to year (P < 0.001 for year-to-year comparisons). Many individuals also appeared to be using antidepressant doses that are probably subtherapeutic, but this finding seemed heavily dependent on the class of antidepressant used. Nearly half of the individuals studied appeared to be treated for inadequately short periods.
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Affiliation(s)
- C Rojas-Fernandez
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Bartels SJ, Horn S, Sharkey P, Levine K. Treatment of depression in older primary care patients in health maintenance organizations. Int J Psychiatry Med 1998; 27:215-31. [PMID: 9565725 DOI: 10.2190/vkbr-1ar6-9nbd-0n25] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy. DESIGN Chart-review, Cross sectional study. SETTING AND PARTICIPANTS Patients were selected from six HMOs in the United States who had one or more of five medical diagnoses: arthritis, asthma, otitis media, epigastric pain/ulcer, and hypertension, (n = 9143). From this group, chart diagnoses and pharmacy records were used to identify patients who also had a diagnosis of depression (n = 416) or who had a diagnosis of depression and/or treatment with antidepressant medication (n = 1286). MEASUREMENT Medical records and computerized service and pharmacy records were reviewed to obtain diagnoses, office visits by provider type, and psychiatric medication prescription counts. RESULTS Significant differences were found in treatment of depression for older versus younger patients. Although depression was identified at a similar rate for both groups, older patients received fewer mental health specialty visits and fewer prescriptions for SSRI antidepressants. Older patients with a diagnosis of depression were more likely to be treated with benzodiazepines (49.2% of older vs. 33.2% of younger) though they were less likely to receive long half-life benzodiazepines. CONCLUSIONS Psychotropic medication management is an important target for improving quality of care for older patients with depression in HMOs. Decreasing inefficient minor tranquilizer use and increasing use of newer antidepressant medications may lead to improved outcomes for older depressed adults.
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Affiliation(s)
- S J Bartels
- Dartmouth Medical School, New Hampshire, USA
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Zhang M, Booth BM, Smith GR. Services utilization before and after the prospective payment system by patients with somatization disorder. J Behav Health Serv Res 1998; 25:76-82. [PMID: 9516296 DOI: 10.1007/bf02287502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study analyzed services utilization before and after the implementation of Medicare's Prospective Payment System (PPS) in psychiatric patients with somatization disorder in two samples: one recruited before the PPS and the other after the PPS. Individuals with this psychiatric disorder present with multiple unexplained medical complaints and consume a great number of health resources. The results from this study indicated that Medicare PPS was associated with fewer hospital admissions and fewer hospital days, with a greater number of physician visits (for Medicare patients) and emergency room visits (for non-Medicare patients) and with lower overall health expenditures. However, there were no significant changes in the average length of stay after PPS. In contrast to previous studies, Medicare PPS was significantly associated with changes in service utilization by non-Medicare patients as well, a possible "spillover effect." This study confirms the results from other research indicating that higher levels of efficiency may be achieved for certain psychiatric disorders through prospective payment mechanisms.
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Affiliation(s)
- M Zhang
- Department of Veterans Affairs Medical Center, Little Rock, AR 72204, USA.
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Moul DE. Mental health services research on the aging: new opportunities and challenges for clinical researchers. J Am Geriatr Soc 1996; 44:999-1000. [PMID: 8708319 DOI: 10.1111/j.1532-5415.1996.tb01879.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- D E Moul
- Chief Aging Mental Health Services Section, National Institute of Mental Health, Rockville, MD 20857, USA
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