1
|
Alshoaibi N, Aljazar A, Bushnag M, Aseeri A, Baeesa L, Alruwaithi S, Bashawri R, Marouf A, Alsaeed R. Assessment of Psychological Implications and Quality of Life After Different Cardiac Device Implantation in Saudi Arabia. Cureus 2024; 16:e52338. [PMID: 38361709 PMCID: PMC10867300 DOI: 10.7759/cureus.52338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Cardiac device therapy is likely to affect different aspects of patients' psychological well-being, such as their quality of life. The aim of this study was to examine the mental health status, specifically the conditions of depression and anxiety regarding implantable cardiac device patients. METHODS A cross-sectional retrospective study was conducted in January 2022. This study was conducted at King Abdul-Aziz University Hospital in Jeddah, Saudi Arabia. All patients aged more than 18 years old who underwent heart device implantation for six months or more formed the study population. A total of 30 implantable cardioverter defibrillator (ICD) subtypes were used in our patients (45.8%), including cardiac resynchronization therapy device (CRT-D) in seven patients (14.6%) and one subcutaneous ICD (2.1%). A pacemaker was used in 18 patients (37.5%). Binary logistic regression analysis was conducted to identify the association between type of cardiac implantation device and the likelihood of having abnormal depression and anxiety score. RESULTS A total of 48 patients participated in this study. Hypertension was the most frequently associated risk factor in our sample (64.6%; n=31). In comparison between ICD users and pacemaker users in terms of the SF-36 general health survey, a marginally significant difference was noted in the role of limitations due to emotional health (63 ± 28.6) for ICD patients compared to pacemaker patients (81.8 ± 28.1), (p=0.050). However, pacemaker patients showed a significant favourable social functioning score (90.1 ± 17.7) compared to ICD patients (71.5 ± 19), (p=0.001). There is no significant difference noted regarding the other domains. Binary logistic regression analysis identified that patients who are using ICD were seven times more likely to have abnormal anxiety score (odds ratio: 7.00 (95% confidence interval: 1.36-35.9) (p=0.020). CONCLUSION This study identified a potential association between cardiac devices and the anxiety and quality of life of patients. Nonetheless, further investigation is warranted to assess the psychological and physiological effects of cardiac device therapy on patients, in addition to examining the effects of implantation and follow-up on cardiac function and cardiac symptoms.
Collapse
Affiliation(s)
| | - Alaa Aljazar
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Maal Bushnag
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Afnan Aseeri
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Layan Baeesa
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Roba Bashawri
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Amjad Marouf
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Refan Alsaeed
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| |
Collapse
|
2
|
Nam J, Sljivic S, Matthews R, Pak J, Agala C, Salamah H, Hatch E, Nizamani R, King B, Laughon SL, Williams FN. The Cost of Mental Health Comorbid Conditions in Burn Patients: A Single-site Experience. J Burn Care Res 2023; 44:751-757. [PMID: 36512488 DOI: 10.1093/jbcr/irac181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Many burn survivors suffer from psychiatric sequelae long after their physical injuries have healed. This may even be more pronounced in individuals who have a history of mental health disorders prior to admission. The aim of this study was to explore the clinical outcomes of patients with previously diagnosed mental health disorders who were admitted to our Burn Center. This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between January 1, 2014 and June 30, 2021 with burn injury or inhalation injury were included in this study. Variables of interest included demographics and burn mechanism. Outcomes of interests were length of stay, cost of hospitalization, and mortality. A P-value of < .05 was considered statistically significant for all analyses. There were 4958 patients included in this study, with 35% of these patients having a previous diagnosis of mental health disorders. Patients with mental health disorders were younger, with larger burns, P < .05. They had significantly longer lengths of stay and significantly higher costs (P < .00001). Mortality for those with a mental health disorder history was 2% and 3% for those without (P = .04). Patients with pre-existing mental health disorders had decreased odds of mortality. However, they do have extended lengths of stay, which may exhaust current sparse staff and burn bed resources.
Collapse
Affiliation(s)
- Jason Nam
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road, Durham, North Carolina 27710, USA
| | - Sanja Sljivic
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
- North Carolina Jaycee Burn Center, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Robert Matthews
- Department of Anesthesiology, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Joyce Pak
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina 27599, USA
| | - Chris Agala
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road, Durham, North Carolina 27710, USA
| | - Hanaan Salamah
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Erica Hatch
- Department of Psychiatry, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Rabia Nizamani
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road, Durham, North Carolina 27710, USA
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Booker King
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road, Durham, North Carolina 27710, USA
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Sarah L Laughon
- Department of Psychiatry, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| | - Felicia N Williams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road, Durham, North Carolina 27710, USA
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, North Carolina 27599, USA
| |
Collapse
|
3
|
Willy K, Ellermann C, Reinke F, Rath B, Wolfes J, Eckardt L, Doldi F, Wegner FK, Köbe J, Morina N. The Impact of Cardiac Devices on Patients’ Quality of Life—A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2022; 9:jcdd9080257. [PMID: 36005421 PMCID: PMC9409697 DOI: 10.3390/jcdd9080257] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/03/2022] [Accepted: 08/06/2022] [Indexed: 12/13/2022] Open
Abstract
The implantation of cardiac devices significantly reduces morbidity and mortality in patients with cardiac arrhythmias. Arrhythmias as well as therapy delivered by the device may impact quality of life of patients concerned considerably. Therefore we aimed at conducting a systematic search and meta-analysis of trials examining the impact of the implantation of cardiac devices, namely implantable cardioverter-defibrillators (ICD), pacemakers and left-ventricular assist devices (LVAD) on quality of life. After pre-registering the trial with the PROSPERO database, we searched Medline, PsycINFO, Web of Science and the Cochrane databases for relevant publications. Study quality was assessed by two independent reviewers using standardized protocols. A total of 37 trials met our inclusion criteria. Of these, 31 trials were cohort trials while 6 trials used a randomized controlled design. We found large pre-post effect sizes for positive associations between quality of life and all types of devices. The effect sizes for LVAD, pacemaker and ICD patients were g = 1.64, g = 1.32 and g = 0.64, respectively. There was a lack of trials examining the effect of implantation on quality of life relative to control conditions. Trials assessing quality of life in patients with cardiac devices are still scarce. Yet, the existing data suggest beneficial effects of cardiac devices on quality of life. We recommend that clinical trials on cardiac devices routinely assess quality of life or other parameters of psychological well-being as a decisive study endpoint. Furthermore, improvements in psychological well-being should influence decisions about implantations of cardiac devices and be part of patient education and may impact shared decision-making.
Collapse
Affiliation(s)
- Kevin Willy
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
- Department of Psychology, University of Münster, 48149 Münster, Germany
- Correspondence: ; Tel.: +49-251-83-44949; Fax: +49-251-83-52980
| | - Christian Ellermann
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Florian Reinke
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Benjamin Rath
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Julian Wolfes
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Lars Eckardt
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Florian Doldi
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Felix K. Wegner
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Julia Köbe
- Department for Cardiology II: Electrophysiology, University Hospital Münster, 48149 Münster, Germany
| | - Nexhmedin Morina
- Department of Psychology, University of Münster, 48149 Münster, Germany
| |
Collapse
|
4
|
Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions. J Gen Intern Med 2022; 37:40-48. [PMID: 34027614 PMCID: PMC8739416 DOI: 10.1007/s11606-021-06884-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/03/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Integrating mental health in primary care settings is associated with improved screening and detection of mental illness. In 2010, the Veterans Health Administration launched a patient-centered medical home (PCMH) model nationally across all clinical sites that integrated mental health into primary care-the Patient Aligned Care Team (PACT) initiative. Team-based delivery of continuous primary and mental health care, as found in effective collaborative care models, is thought to be crucial to managing veterans with mental health disorders. The association between clinic implementation of specific aspects of PACT and clinical outcomes of veterans with mental health disorders remains unknown. OBJECTIVE To examine the association between clinic implementation of team-based care and continuity of care and subsequent hospitalizations among veterans with mental health disorders. DESIGN Retrospective cohort study. PATIENTS A total of 1,444,942 veterans with comorbid mental health disorders and physical health conditions receiving primary care in 831 VA PACT clinics in fiscal year (FY) 2015. MAIN MEASURES We examined the clinic-level implementation of team-based care and continuity of care in the clinic where veterans received their primary care. Our primary outcome was any hospitalization in the VA or fee-based service in FY2016. We examined the impact of clinic-level implementation of team-based care and continuity of care on having a hospitalization, adjusting for patient demographic, clinical characteristics, and facility characteristics. KEY RESULTS Veterans receiving care in clinics with the greatest versus lowest quartile of implementation of team-based care had lower rates of hospitalization (8.8% vs. 12.3%; adjusted OR = 0.92, 95% CI 0.85-0.99, p < 0.035). There was not a statistically significant association between clinic-level implementation of continuity of care and hospitalization. CONCLUSIONS Veterans receiving care in clinics with greater implementation of team-based care had statistically significant lower rates of hospitalization.
Collapse
|
5
|
Kuruppu S, Ghani M, Pritchard M, Harris M, Weerakkody R, Stewart R, Perera G. A prospective investigation of depression and adverse outcomes in patients undergoing vascular surgical interventions: A retrospective cohort study using a large mental health database in South London. Eur Psychiatry 2021; 64:e13. [PMID: 33455615 PMCID: PMC8057466 DOI: 10.1192/j.eurpsy.2021.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/07/2020] [Accepted: 01/07/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients with depression are more susceptible to cardiovascular illness including vascular surgeries. However, health outcomes after vascular surgery among patients with depression is unknown. This study aimed to investigate associations of depression with post-operative health outcomes for vascular surgical patients. METHODS A retrospective observational study was conducted using data from a large mental healthcare provider and linked national hospitalization data for the same south London geographic catchment. OPCS-4 codes were used to identify vascular procedures. Health outcomes were compared between those with/without depression including length of hospital stay (LOS), inpatient mortality, and 30 day emergency hospital readmissions. Predictors of these health outcomes were also assessed. RESULTS Vascular surgery was received by 9,267 patients, including 446 diagnosed with depression. Patients with depression had a higher risk of emergency admission for vascular surgery (odds ratio [OR] 1.28; 1.03, 1.59), longer index LOS (IRR 1.38; 1.33-1.42), and a higher risk of 30-day emergency readmission (OR 1.82; 1.35-2.47). Patients with depression had higher inpatient mortality after adjustment for sociodemographic status (1.51; 1.03, 2.23) but not on full adjustment, and had longer emergency readmission LOS (1.13; 1.04, 1.22) after adjustment for sociodemographic factors and cardiovascular disease. Correlates of vascular surgery hospitalization among patients with depression included admission through emergency route for longer LOS, inpatient mortality, and 30-day hospital readmission. CONCLUSION Patients with depression undergoing vascular surgery have substantially poorer health outcomes. Screening for depression prior to surgery might be indicated to target preventative measures.
Collapse
Affiliation(s)
- Sajini Kuruppu
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience. King’s College London. United Kingdom
| | - Marvey Ghani
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience. King’s College London. United Kingdom
| | - Megan Pritchard
- SLaM BRC Nucleus, South London and Maudsley NHS Foundation Trust. London. United Kingdom
| | - Matthew Harris
- Department of Vascular Surgery, The Royal Free Hospital, Pond Street, LondonNW3 2QG, United Kingdom
- King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | - Ruwan Weerakkody
- Department of Vascular Surgery, The Royal Free Hospital, Pond Street, LondonNW3 2QG, United Kingdom
- King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience. King’s College London. United Kingdom
- SLaM BRC Nucleus, South London and Maudsley NHS Foundation Trust. London. United Kingdom
| | - Gayan Perera
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience. King’s College London. United Kingdom
- SLaM BRC Nucleus, South London and Maudsley NHS Foundation Trust. London. United Kingdom
| |
Collapse
|
6
|
Owen-Smith A, Stewart C, Sesay MM, Strasser SM, Yarborough BJ, Ahmedani B, Miller-Matero LR, Waring SC, Haller IV, Waitzfelder BE, Sterling SA, Campbell CI, Hechter RC, Zeber JE, Copeland LA, Scherrer JF, Rossom R, Simon G. Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness. BMC Psychiatry 2020; 20:40. [PMID: 32005200 PMCID: PMC6995196 DOI: 10.1186/s12888-020-2456-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/22/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. METHODS Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. RESULTS Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. CONCLUSIONS Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.
Collapse
Affiliation(s)
- Ashli Owen-Smith
- Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA, 30303, USA. .,Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA.
| | - Christine Stewart
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
| | - Musu M. Sesay
- 0000 0000 9957 7758grid.280062.eCenter for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA
| | - Sheryl M. Strasser
- 0000 0004 1936 7400grid.256304.6Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA 30303 USA
| | - Bobbi Jo Yarborough
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Northwest, Portland, USA
| | - Brian Ahmedani
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Lisa R. Miller-Matero
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Stephen C. Waring
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Irina V. Haller
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Beth E. Waitzfelder
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Hawaii, Honolulu, USA
| | - Stacy A. Sterling
- 0000 0000 9957 7758grid.280062.eDivision of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Cynthia I. Campbell
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Rulin C. Hechter
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John E. Zeber
- 0000 0001 2184 9220grid.266683.fSchool of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, USA
| | | | - Jeffrey F. Scherrer
- 0000 0004 1936 9342grid.262962.bDepartment of Family and Community Medicine, Saint Louis University School of Medicine, Saint Louis, USA
| | - Rebecca Rossom
- 0000 0004 0461 4886grid.280625.bHealth Partners Institute, Minneapolis, USA
| | - Greg Simon
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
| |
Collapse
|
7
|
Stock EM, Zeber JE, McNeal CJ, Banchs JE, Copeland LA. Psychotropic Pharmacotherapy Associated With QT Prolongation Among Veterans With Posttraumatic Stress Disorder. Ann Pharmacother 2018; 52:838-848. [DOI: 10.1177/1060028018769425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: In 2012, the Food and Drug Administration issued Drug Safety Communications on several drugs associated with QT prolongation and fatal ventricular arrhythmias. Among these was citalopram, a selective serotonin reuptake inhibitor (SSRI) approved for depression and commonly used for posttraumatic stress disorder (PTSD). Evaluation of the risk for QT prolongation among other psychotropic drugs for individuals with PTSD remains limited. Objective: Explore psychotropic drugs associated with QT prolongation among veterans with PTSD. Methods: Patients in the Veterans Health Administration in 2006-2009 with PTSD and QT prolongation (176 cases) were matched 1:4 on age, gender, visit date and setting, and physical comorbidity. Classification trees assessed QT prolongation risk among prescribed medications (n=880). Results: Receipt of any drug with known risk of QT prolongation varied by group (23% QT cases vs 15% control, p<0.01). Psychotropic medications conferring significant risks included ziprasidone (3% vs 1%, p=0.02) and buspirone (6% vs 2%, p=0.01). Increased risk was not observed for the SSRIs, citalopram and fluoxetine. Classification trees found that sotalol and amitriptyline carried greater risk among cardiac patients and methadone, especially if prescribed with quetiapine, among noncardiac patients. Per adjusted survival model, patients with QT prolongation were at increased risk for death (hazard ratio=1.60; 95% CI=1.04-2.44). Conclusions: Decision models are particularly advantageous when exploring nonlinear relationships or nonadditive interactions. These findings may potentially affect clinical decision-making concerning treatment for PTSD. For patients at higher risk of QT prolongation, antidepressants other than amitriptyline should be considered. Medications for comorbid conditions should also be closely monitored for heightened QT prolongation risk.
Collapse
Affiliation(s)
- Eileen M. Stock
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point, MD, USA
| | - John E. Zeber
- Central Texas Veterans Health Care System, Temple, TX, USA
- Center for Applied Health Research, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M Health Science Center, Bryan, TX, USA
| | - Catherine J. McNeal
- Texas A&M Health Science Center, Bryan, TX, USA
- Department of Cardiology, Baylor Scott & White Health, Temple, TX, USA
| | - Javier E. Banchs
- Department of Electrophysiology and Pacing, Baylor Scott & White Health, Temple, TX, USA
| | - Laurel A. Copeland
- Center for Applied Health Research, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M Health Science Center, Bryan, TX, USA
- VA Central Western Massachusetts, Leeds, MA, USA
| |
Collapse
|
8
|
Mozer AB, Speicher JE, Anciano CJ. Thoracic Surgery Considerations in the Mentally Ill or Handicapped Patient. Thorac Surg Clin 2017; 28:59-68. [PMID: 29150038 DOI: 10.1016/j.thorsurg.2017.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Increasing prevalence of mentally ill and handicapped populations requiring surgical thoracic interventions has brought to light their worse associated morbidity and mortality. Baseline functional status, caretaker environment, and mental limitations in day to day life have an impact in the short and long term from these interventions. Aggressive perioperative care, multispecialty approach, technical aspects, palliative procedures, and ethical considerations all play a part in improving outcomes. In this article real cases are presented illustrating points of care and situations for discussion.
Collapse
Affiliation(s)
- Anthony B Mozer
- General Surgery Resident, Department of Surgery, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA
| | - James E Speicher
- Thoracic and Foregut Surgery, Department of Cardiovascular Sciences, East Carolina University, 115 Heart Drive, Greenville, NC 27834, USA
| | - Carlos J Anciano
- Thoracic and Foregut Surgery, Department of Cardiovascular Sciences, East Carolina University, 115 Heart Drive, Greenville, NC 27834, USA; Minimally Invasive Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, 115 Heart Drive, Greenville, NC 27834, USA.
| |
Collapse
|
9
|
Huffman JC, Adams CN, Celano CM. Collaborative Care and Related Interventions in Patients With Heart Disease: An Update and New Directions. PSYCHOSOMATICS 2017; 59:1-18. [PMID: 29078987 DOI: 10.1016/j.psym.2017.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/13/2017] [Accepted: 09/13/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Psychiatric disorders, such as depression, are very common in cardiac patients and are independently linked to adverse cardiac outcomes, including mortality. Collaborative care and other integrated care models have been used successfully to manage psychiatric conditions in patients with heart disease, with beneficial effects on function and other outcomes. Novel programs using remote delivery of mental health interventions and promotion of psychological well-being may play an increasingly large role in supporting cardiovascular health. METHODS We review prior studies of standard and expanded integrated care programs among patients with cardiac disease, examine contemporary intervention delivery methods (e.g., Internet or mobile phone) that could be adapted for these programs, and outline mental health-related interventions to promote healthy behaviors and overall recovery across all cardiac patients. RESULTS Standard integrated care models for mental health disorders are effective at improving mood, anxiety, and function in patients with heart disease. Novel, "blended" collaborative care models may have even greater promise in improving cardiac outcomes, and interfacing with cardiac patients via mobile applications, text messages, and video visits may provide additional benefit. A variety of newer interventions using stress management, mindfulness, or positive psychology have shown promising effects on mental health, health behaviors, and overall cardiac outcomes. CONCLUSIONS Further study of novel applications of collaborative care and related interventions is warranted given the potential of these programs to increase the reach and effect of mental health interventions in patients with heart disease.
Collapse
Affiliation(s)
- Jeff C Huffman
- Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Caitlin N Adams
- Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | |
Collapse
|
10
|
Perioperative depression or anxiety and postoperative mortality in cardiac surgery: a systematic review and meta-analysis. Heart Vessels 2017; 32:1458-1468. [DOI: 10.1007/s00380-017-1022-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
|
11
|
Cho J, Copeland LA, Stock EM, Zeber JE, Restrepo MI, MacCarthy AA, Ory MG, Smith PA, Stevens AB. Protective and Risk Factors for 5-Year Survival in the Oldest Veterans: Data from the Veterans Health Administration. J Am Geriatr Soc 2017; 64:1250-7. [PMID: 27321603 DOI: 10.1111/jgs.14161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To characterize physical and mental diseases and use of healthcare services and identify factors associated with mortality in the oldest individuals using the Veterans Health Administration (VHA). DESIGN Retrospective study with 5-year survival follow-up. SETTING VHA, system-wide. PARTICIPANTS Veterans using the VHA aged 80 and older as of October 2008 (N = 721,588: n = 665,249 aged 80-89, n = 56,118 aged 90-99, n = 221 aged 100-115). MEASUREMENTS Demographic characteristics, physical and mental diseases, healthcare services, and 5-year survival were measured. RESULTS Accelerated failure time models identified protective and risk factors associated with mortality according to age group. During 5 years of follow-up, 44% of participants died (survival rate: 59% aged 80-89, 32% aged 90-99, 15% aged ≥100). In the multivariable model, protective effects for veterans aged 80-99 were female sex, minority race or ethnicity, being married, having certain physical and mental diagnoses (hypertension, cataract, dyslipidemia, posttraumatic stress disorder, bipolar disorder), having urgent care visits, having invasive surgery, and having few (1-3) prescriptions. Risk factors were lower VHA priority status, physical and mental conditions (diabetes mellitus, anemia, congestive heart failure, dementia, anxiety, depression, smoking, substance abuse disorder), hospital admission, and nursing home care. For those aged 100 and older, being married, smoking, hospital admission, nursing home care, invasive surgery, and prescription use were significant risk factors; only emergency department (ED) use was protective. CONCLUSION Although the data are limited to VHA care (thus missing Medicare services), this study shows that many veterans served by the VHA live to advanced old age despite multiple chronic conditions. Further study is needed to determine whether a comprehensive, coordinated care system like VHA is associated with greater longevity for very old persons.
Collapse
Affiliation(s)
- Jinmyoung Cho
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas
| | - Laurel A Copeland
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - Eileen M Stock
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - John E Zeber
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - Marcos I Restrepo
- University of Texas Health Science Center San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
| | | | - Marcia G Ory
- Texas A&M Health Science Center, College Station, Texas
| | | | - Alan B Stevens
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas
| |
Collapse
|
12
|
Abstract
Anxiety and its associated disorders are common in patients with cardiovascular disease and may significantly influence cardiac health. Anxiety disorders are associated with the onset and progression of cardiac disease, and in many instances have been linked to adverse cardiovascular outcomes, including mortality. Both physiologic (autonomic dysfunction, inflammation, endothelial dysfunction, changes in platelet aggregation) and health behavior mechanisms may help to explain the relationships between anxiety disorders and cardiovascular disease. Given the associations between anxiety disorders and poor cardiac health, the timely and accurate identification and treatment of these conditions is of the utmost importance. Fortunately, pharmacologic and psychotherapeutic interventions for the management of anxiety disorders are generally safe and effective. Further study is needed to determine whether interventions to treat anxiety disorders ultimately impact both psychiatric and cardiovascular health.
Collapse
|
13
|
Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina. Am J Med Sci 2015; 350:263-7. [PMID: 26351774 DOI: 10.1097/maj.0000000000000560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.
Collapse
|
14
|
Hwa KJ, Dua MM, Wren SM, Visser BC. Missing the obvious: psychosocial obstacles in Veterans with hepatocellular carcinoma. HPB (Oxford) 2015; 17:1124-9. [PMID: 26374349 PMCID: PMC4644365 DOI: 10.1111/hpb.12508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Socioeconomic disparities in patients with hepatocellular carcinoma (HCC) influence medical treatment. In addition to socioeconomic barriers, the Veteran population suffers from significant psychosocial obstacles. This study identifies the social challenges that Veterans face while undergoing treatment for HCC. METHODS One hundred Veterans at the Palo Alto VA treated for HCC from 2009 to 2014 (50 consecutive patients who underwent a surgical procedure; 50 treated with intra-arterial therapy) were retrospectively reviewed. RESULTS Substance abuse history was identified in 96%, and half were unemployed. Most patients survived on a limited income [median $1340, interquartile range (IQR) 900-2125]; 36% on ≤ $1000/month, 37% between $1001-2000/month and 27% with >$2000/month. A history of homelessness was found in 30%, more common in those of the lowest income (57% of ≤$1K/month group, 23% of $1-2K/month group and 9% of >$2K/month group, P < 0.01). Psychiatric illness was present in 64/100 patients; among these the majority received ongoing psychiatric treatment. Transportation was provided to 23% of patients who would otherwise have been unable to attend medical appointments. CONCLUSIONS Psychiatric disease and substance abuse are highly prevalent among Veterans with HCC. Most patients survive on a very meager income. These profound socioeconomic and psychosocial problems must be recognized when providing care for HCC to this population to provide adequate treatment and surveillance.
Collapse
Affiliation(s)
- Kimberly J Hwa
- Department of Surgery, Palo Alto Veterans AffairsPalo Alto, CA, USA
| | - Monica M Dua
- Department of Surgery, Stanford University School of MedicineStanford, CA, USA
| | - Sherry M Wren
- Department of Surgery, Palo Alto Veterans AffairsPalo Alto, CA, USA,Department of Surgery, Stanford University School of MedicineStanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Palo Alto Veterans AffairsPalo Alto, CA, USA,Department of Surgery, Stanford University School of MedicineStanford, CA, USA
| |
Collapse
|
15
|
Abstract
BACKGROUND Anticipating poor recovery due to impaired self-management and appointment-keeping, clinicians may consider serious mental illness (SMI) a significant concern in organ transplantation. However, little empirical evidence exists regarding posttransplantation outcomes for patients with SMI. METHODS This study analyzed health services data to evaluate posttransplantation 3-year survival by SMI status in a nationwide cohort of patients in the Veterans Health Administration (VHA). RESULTS A total of 960 recipients of solid organ or bone marrow transplants were identified from Veterans Health Administration administrative data extracts for fiscal years 2006 to 2009. Of these, 164 (17%) had an SMI diagnosis before transplantation (schizophrenia, posttraumatic stress, major depressive, and bipolar disorders); 301 (31%) had some other mental illness diagnosis (such as anxiety, adjustment reactions, or substance abuse); and 495 (52%) had no mental health diagnosis. Twenty-two patients (2%) required retransplantation and 208 patients (22%) died during follow-up. Data on whether these were primary or repeat transplantations were unavailable. Rates of attendance at postoperative outpatient visits and number of months for which immunosuppressive drugs fills were recorded were similar among mental illness groups, as were rates of diagnosed immunological rejection. Three-year mortality was equivalent among mental health groups: no mental health (19%) versus other mental illness (23%) versus SMI (27%; χ(2) = 5.11; df = 2; P = .08). In adjusted survival models, no effect of mental health status was observed. CONCLUSIONS Serious mental illness diagnosis does not appear to be associated with adverse transplantation outcomes over the first 3 years; however, a potentially diverging survival curve may portend higher mortality at 5 years.
Collapse
|
16
|
Copeland LA, Zeber JE, Sako EY, Mortensen EM, Pugh MJ, Wang CP, Restrepo MI, Flynn J, MacCarthy AA, Lawrence VA. Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration. BMC Surg 2015; 15:74. [PMID: 26084521 PMCID: PMC4472400 DOI: 10.1186/s12893-015-0064-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 06/11/2015] [Indexed: 11/10/2022] Open
Abstract
Background The STOPP study (Surgical Treatment Outcomes for Patients with Psychiatric Disorders) analyzed variation in rates and types of major surgery by serious mental illness status among patients treated in the Veterans Health Administration (VA). VA patients are veterans of United States military service who qualify for federal care by reason of disability, special service experiences, or poverty. Methods STOPP conducted a secondary data analysis of medical record extracts for seven million VA patients treated Oct 2005-Sep 2009. The retrospective study aggregated inpatient surgery events, comorbid diagnoses, demographics, and postoperative 30-day mortality. Results Serious mental illness -- schizophrenia, bipolar disorder, posttraumatic stress disorder, or major depressive disorder, was identified in 12 % of VA patients. Over the 4-year study period, 321,131 patients (4.5 %) underwent surgery with same-day preoperative or immediate post-operative admission including14 % with serious mental illness. Surgery patients were older (64 vs. 61 years) and more commonly African-American, unmarried, impoverished, highly disabled (24 % vs 12 % were Priority 1), obese, with psychotic disorder (4.3 % vs 2.9 %). Among surgery patients, 3.7 % died within 30 days postop. After covariate adjustment, patients with pre-existing serious mental illness were relatively less likely to receive surgery (adjusted odds ratios 0.4-0.7). Conclusions VA patients undergoing major surgery appeared, in models controlling for comorbidity and demographics, to disproportionately exclude those with serious mental illness. While VA preferentially treats the most economically and medically disadvantaged veterans, the surgery subpopulation may be especially ill, potentially warranting increased postoperative surveillance.
Collapse
Affiliation(s)
- Laurel A Copeland
- Veterans Affairs: Central Texas Veterans Health Care System, Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA. .,Baylor Scott & White Health: Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA. .,Texas A&M Health Science Center, College of Medicine, Bryan, TX, USA. .,UT Health Science Center San Antonio, San Antonio, TX, USA.
| | - John E Zeber
- Veterans Affairs: Central Texas Veterans Health Care System, Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA.,Baylor Scott & White Health: Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA.,Texas A&M Health Science Center, College of Medicine, Bryan, TX, USA.,UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Edward Y Sako
- UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Eric M Mortensen
- Veterans Affairs: North Texas Veterans Health Care System, 4500 S. Lancaster Rd, Dallas, TX, 75216, USA.,UT Southwestern Medical Center, Dallas, TX, USA
| | - Mary Jo Pugh
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Chen-Pin Wang
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Marcos I Restrepo
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Julianne Flynn
- Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Andrea A MacCarthy
- Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | | |
Collapse
|
17
|
Case DJ, Copeland LA, Stock EM, Herrera HR, Pfanner TP. Pneumococcal vaccination rates in VHA patients with inflammatory bowel disease. Medicine (Baltimore) 2015; 94:e417. [PMID: 25674731 PMCID: PMC4602733 DOI: 10.1097/md.0000000000000417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Inflammatory bowel disease (IBD) is an inflammatory condition of the digestive tract not caused by infectious agents. Symptoms of IBD, such as diarrhea and pain, diminish one's quality of life. Underlying immune dysregulation may put IBD patients at risk for severe infectious disease making preventative vaccination highly recommended. Therefore, this study sought to assess rates of pneumococcal vaccination in patients with IBD.A cross-sectional observational study was employed utilizing administrative data extracts from the Veterans Health Administration (VHA) to identify patients diagnosed with IBD per International Classification of Diseases, Version 9, Clinical Modification codes. Their pneumococcal vaccine histories were determined from Common Procedural Terminology codes. Data were aggregated to the patient level and subjected to multivariable logistic regression to assess factors associated with receipt of the vaccination and 1-year mortality; survival analyses extended follow-up to as much as 4 years following IBD diagnosis.From October 2004 to September 2009, 49,350 patients were diagnosed with IBD in the VHA. Incidence was approximately 6000 cases/y. Patients averaged 62 years (±15, range 19-98) with 45% aged 65 or older. Approximately 6% were women, 21% were highly disabled from a military service-connected condition, 46% had hypertension, 38% dyslipidemia, and 18% diabetes. Only 20% of the cohort received pneumococcal vaccination including 5% vaccinated prior to IBD diagnosis, 2% on the date of diagnosis, and 13% subsequently. Being married, living outside the Northeast, and having more comorbidities were associated with vaccination before IBD diagnosis; models of vaccination at or after diagnosis demonstrated poor fit: little better than chance. Vaccinations before, after, and at diagnosis were protective against 1-year mortality adjusting for clinical and demographic covariates. Living in the South was an independent risk factor for death among IBD patients.While vaccination for pneumococcus is a low-cost, low-risk recommendation for persons with IBD with an apparent survival benefit, vaccination rates were low.
Collapse
Affiliation(s)
- David J Case
- From the Department of Internal Medicine (DJC, HRH, TPP), Gastroenterology Service, Baylor Scott & White Health; Texas A&M Health Science Center (DJC, LAC, EMS, HRH, TPP); Center for Applied Health Research (LAC, EMS), Central Texas Veterans Health Care System, jointly with Baylor Scott & White Health, Temple, TX
| | | | | | | | | |
Collapse
|
18
|
von Esenwein SA, Druss BG. Using electronic health records to improve the physical healthcare of people with serious mental illnesses: a view from the front lines. Int Rev Psychiatry 2014; 26:629-37. [PMID: 25553780 DOI: 10.3109/09540261.2014.987221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Individuals with serious mental illnesses (SMI) treated in the public mental health sector die decades younger than the general population. Poor quality and fragmentation of care are risk factors underlying the poor health of this population. Integrated electronic health records (EHR) can play a vital role in efforts to improve quality and outcomes of care in patients with SMI. The objective of this paper is to describe the current state of efforts to integrate and improve the mental and physical care of individuals with SMI in the public sector, with an emphasis on the use of electronic health records (EHR). While a range of encouraging initiatives exists throughout the country, technological and medico-legal challenges are providing significant barriers for the successful integration of care and EHRs for many partnering organizations. Furthermore, there is a lack of rigorous research studying the effectiveness and sustainability of these programmes. Recommendations are made for the alleviation of policy barriers and future areas of inquiry.
Collapse
Affiliation(s)
- Silke A von Esenwein
- Center for Behavioral Health Policy Studies, Rollins School of Public Health, Emory University , Atlanta, Georgia , USA
| | | |
Collapse
|