Comorbidities, healthcare use, and contact with healthcare transition services in older veterans after incarceration

BACKGROUND

The Health Care for Reentry Veterans (HCRV) program was established to support community reintegration for veterans after incarceration. Yet, it is unclear how those with and without HCRV contact differ. We sought to evaluate differences in medical and psychiatric conditions and healthcare utilization among mid-to late-life reentry veterans who did and did not receive HCRV outreach.

METHODS

Study participants were veterans aged ≥50 years who qualified for Medicare fee-for-service, had experienced incarceration for ≥1 year, and were released from incarceration between October 1, 2006, and September 30, 2018 (N = 9733). Using VA and Medicare claims data, we compared prevalence of medical and psychiatric diagnoses, and use of emergency, inpatient, and outpatient medical and mental health services up to 12 months after release between those with and without HCRV contact.

RESULTS

Veterans with HCRV contact (35.5%) had significantly higher rates of psychiatric conditions and medical conditions related to substance use (e.g., liver disease) compared to veterans without HCRV contact. Average time between release and first healthcare service use was significantly lower for HCRV veterans (36.5 ± SD 59.5 days) versus non-HCRV veterans (58.9 ± SD 77.5 days) and HCRV veterans were more likely to utilize the emergency department, inpatient and outpatient mental health services, and inpatient medical services.

CONCLUSION

HCRV reaches older reentry veterans with a large burden of mental health and substance use disorders. However, levels of multimorbidity were high among all older reentry veterans, pointing to a need to develop specialized geriatric models of care for this reentry population.

Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis

Importance

Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability.

Objective

To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds.

Data Sources

A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022.

Study Selection

Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable.

Data Extraction and Synthesis

Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022.

Main Outcome(s) and Measure(s)

Risk of physical restraint use in adult ED patients by racial and ethnic background.

Results

The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89).

Conclusions and Relevance

Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.

Breast Cancer Screening Rates Among Medicaid Beneficiaries With Schizophrenia

OBJECTIVE

Women with serious mental illness are more likely to be diagnosed as having late-stage breast cancer than women without serious mental illness, suggesting a disparity in screening mammography. This study aimed to compare screening mammography rates in a nationally representative sample of Medicaid beneficiaries with and without schizophrenia.

METHODS

Medicaid Analytic eXtract files, 2007-2012, were used to identify a cohort of women ages 40-64 with schizophrenia who were eligible for Medicaid but not Medicare (N=87,572 in 2007 and N=114,341 in 2012) and a cohort without schizophrenia, frequency-matched by age, race-ethnicity, and state (N=97,003 in 2007 and N=126,461 in 2012). Annual screening mammography rates were calculated and adjusted for demographic characteristics and comorbid conditions. Multivariable logistic regression was used to estimate the association between beneficiary characteristics and screening mammography rates.

RESULTS

In 2012, 27.2% of women with schizophrenia completed screening mammography, compared with 26.8% of the control cohort. In the schizophrenia cohort, American Indian/Alaskan Native women had significantly lower odds of receiving mammography (OR=0.82, p=0.02) than White women, whereas Hispanic/Latina women had higher odds (OR=1.16, p<0.001). Women with schizophrenia and a nonalcohol-related substance use disorder had lower odds of receiving mammography (OR=0.74, p<0.001) than women without a substance use disorder. Having at least one medical visit in the past year (vs. no visits) increased the odds of receiving screening mammography (OR=5.08, p<0.001).

CONCLUSIONS

Screening mammography rates were similar between Medicaid-insured women with and those without schizophrenia. Interventions to increase uptake may need to focus on improving socioeconomic conditions and primary care engagement for vulnerable populations, regardless of psychiatric condition.

CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care

BACKGROUND

Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care.

METHODS

The study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites.

RESULTS

Rates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P &lt; .001]. While we observed a significant increase in A1c screening rates at the intervention site, this increase did not persist after multivariable adjustment (aOR 1.37, 95% CI .95-1.99, P = .09).

CONCLUSIONS

This low-cost, reverse integrated care model targeting community psychiatrist practices had modest effects on increasing preventive care screenings, with the biggest effect seen for HIV testing rates. Additional incentives and structural supports may be needed to further promote screening practices for individuals with serious mental illness.

Climate Change and Mental Health: Implications for the Psychiatric Workforce

Climate change is a major global public mental health crisis that is expected to increase the need for mental health services. Psychiatrists and other mental health care providers must address workforce needs through recruitment, training and education, prevention and intervention, public policy and advocacy, and direct efforts to reduce climate change. This column discusses concrete steps for the psychiatric workforce to take to prepare for growing mental health needs associated with climate change.

Climate change and mental health research methods, gaps, and priorities: a scoping review

Research on climate change and mental health is a new but rapidly growing field. To summarise key advances and gaps in the current state of climate change and mental health studies, we conducted a scoping review that comprehensively examined research methodologies using large-scale datasets. We identified 56 eligible articles published in Embase, PubMed, PsycInfo, and Web of Science between Jan 1, 2000, and Aug 9, 2020. The primary data collection method used was surveys, which focused on self-reported mental health effects due to acute and subacute climate events. Other approaches used administrative health records to study the effect of environmental temperature on hospital admissions for mental health conditions, and national vital statistics to assess the relationship between environmental temperature and suicide rates with regression analyses. Our work highlights the need to link population-based mental health outcome databases to weather data for causal inference. Collaborations between mental health providers and data scientists can guide the formation of clinically relevant research questions on climate change.

Impact of a Same-Day Breast Biopsy Program on Disparities in Time to Biopsy for Patients With Serious Mental Illness

PURPOSE

The aim of this study was to investigate disparities in time between breast biopsy recommendation and completion and the impact of a same-day biopsy (SDB) program for patients with serious mental illness (SMI), with a focus on more vulnerable individuals with public payer insurance.

METHODS

In August 2017, the authors' academic breast imaging center started routinely offering needle biopsies on the day of recommendation. Primary outcomes were the proportion of biopsies performed as SDBs and days from biopsy recommendation to completion over a 2.5-year pre- versus postintervention period, comparing all patients with SMI versus those without, and public payer-insured patients <65 years of age with SMI (SMI-PP) versus without SMI (non-SMI-PP). Multivariable proportional odds and logistic regression models were fit to assess association of SMI status, age, race/ethnicity, language, and insurance with days to biopsy and SDB within each period.

RESULTS

There were 2,026 biopsies preintervention and 2,361 biopsies postintervention. Preintervention, 8.43% of patients with SMI (7 of 83) underwent SDB compared with 15.59% of those without SMI (303 of 1,943) (P = .076), and 2.7% of the SMI-PP subgroup (1 of 37) underwent SDB compared with 15.88% of the non-SMI-PP subgroup (47 of 296) (P = .031). Adjusted for age, race/ethnicity, and language, disparities persisted in odds for undergoing SDB (adjusted odds ratio, 0.13; 95% confidence interval, 0.02-0.92; P = .04) and having longer days to biopsy (adjusted odds ratio, 2.35; 95% confidence interval, 1.26-4.37; P = .01) for the SMI-PP subgroup compared with the non-SMI-PP subgroup in the preintervention period. There was no evidence of these disparities postintervention for the SMI-PP subgroup. SDB proportion increased from 15.3% (310 of 2,026) to 36.09% (852 of 2,361) (P < .001) across all patients.

CONCLUSIONS

A same-day breast biopsy program mitigates disparities in time to biopsy for patients with SMI and helps improve breast cancer care equity for this vulnerable population.

The Effects of Climate Change on Child and Adolescent Mental Health: Clinical Considerations

PURPOSE OF REVIEW

We review recent literature on the effects of climate change on child and adolescent mental health and discuss treatment and engagement by clinicians.

RECENT FINDINGS

Climate change affects child and adolescent mental health in many intersecting ways, including as a social and ecological determinant of health, a threat amplifier, and a source of trauma and distress. Single extreme weather events contribute to significant negative mental health consequences; however, subacute and chronic climate events also have mental health sequelae. Furthermore, awareness of the climate crisis is associated with emotional distress. Young people with pre-existing mental illness and lacking social support may be at elevated risk for climate change-related mental health effects. Climate activism is associated with resilience and positive development, but may also be a source of increased stress, particularly for marginalized youths. Climate change can affect the mental health of children and adolescents in complex and diverse ways. Sources of coping and resilience also vary greatly between individuals. Mental health clinicians must respond to this existential crisis by addressing research gaps in this area, obtaining relevant clinical training, educating their communities, and joining and supporting young people in their advocacy efforts.

Development and Implementation of a Chief Resident for Research Role in a Psychiatry Residency Training Program

Psychiatry residency programs with robust research training can prepare physician-scientists to make contributions that advance the mental health field. Our psychiatry residency developed a chief resident for research position to help provide mentorship, community building, and advising around scholarly activities for residents. We present the process of implementing this new position in our residency to offer a model for engaging psychiatry residents in research.

Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system

INTRODUCTION

Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population.

METHODS

We conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility.

RESULTS

Of the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions.

CONCLUSIONS

These findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.

The Effects of Public Disclosure of Industry Payments to Physicians on Patient Trust: A Randomized Experiment

BACKGROUND

Financial ties between physicians and the pharmaceutical and medical device industry are common, but little is known about how patient trust is affected by these ties.

OBJECTIVE

The purpose of this study was to evaluate how viewing online public disclosure of industry payments affects patients' trust ratings for physicians, the medical profession, and the pharmaceutical and medical device industry.

DESIGN

This was a randomized experimental evaluation.

PARTICIPANTS

There were 278 English-speaking participants over age 18 who had seen a healthcare provider in the previous 12 months who took part in the study.

INTERVENTIONS

Participants searched for physicians on an online disclosure database, viewed payments from industry to the physicians, and assigned trust ratings. Participants were randomized to view physicians who received no payment ($0), low payment ($250-300), or high payment (>$13,000) from industry, or to a control arm in which they did not view the disclosure website. They also were asked to search for and then rate trust in their own physician.

MAIN MEASURES

Primary outcomes were trust in individual physician, medical profession, and industry. These scales measure trust as a composite of honesty, fidelity, competence, and global trust.

KEY RESULTS

Compared to physicians who received no payments, physicians who received payments over $13,000 received lower ratings for honesty [mean (SD): 3.36 (0.86) vs. 2.75 (0.95), p < 0.001] and fidelity [3.19 (0.65) vs. 2.89 (0.68), p = 0.01]. Among the 7.9% of participants who found their own physician on the website, ratings for honesty and fidelity decreased as the industry payment to the physician increased (honesty: Spearman's ρ = -0.52, p = 0.02; fidelity: Spearman's ρ = -0.55, p = 0.01). Viewing the disclosure website did not affect trust ratings for the medical profession or industry.

CONCLUSIONS

Disclosure of industry payments to physicians affected perceptions of individual physician honesty and fidelity, but not perceptions of competence. Disclosure did not affect trust ratings for the medical profession or the pharmaceutical and medical device industry. ClinicalTrials.gov identifier: NCT02179632 ( https://clinicaltrials.gov/ct2/show/NCT02179632 ).

Social network targeting to maximise population behaviour change: a cluster randomised controlled trial

BACKGROUND

Information and behaviour can spread through interpersonal ties. By targeting influential individuals, health interventions that harness the distributive properties of social networks could be made more effective and efficient than those that do not. Our aim was to assess which targeting methods produce the greatest cascades or spillover effects and hence maximise population-level behaviour change.

METHODS

In this cluster randomised trial, participants were recruited from villages of the Department of Lempira, Honduras. We blocked villages on the basis of network size, socioeconomic status, and baseline rates of water purification, for delivery of two public health interventions: chlorine for water purification and multivitamins for micronutrient deficiencies. We then randomised villages, separately for each intervention, to one of three targeting methods, introducing the interventions to 5% samples composed of either: randomly selected villagers (n=9 villages for each intervention); villagers with the most social ties (n=9); or nominated friends of random villagers (n=9; the last strategy exploiting the so-called friendship paradox of social networks). Participants and data collectors were not aware of the targeting methods. Primary endpoints were the proportions of available products redeemed by the entire population under each targeting method. This trial is registered with ClinicalTrials.gov, number NCT01672580.

FINDINGS

Between Aug 4, and Aug 14, 2012, 32 villages in rural Honduras (25-541 participants each; total study population of 5773) received public health interventions. For each intervention, nine villages (each with 1-20 initial target individuals) were randomised, using a blocked design, to each of the three targeting methods. In nomination-targeted villages, 951 (74·3%) of 1280 available multivitamin tickets were redeemed compared with 940 (66·2%) of 1420 in randomly targeted villages and 744 (61·0%) of 1220 in indegree-targeted villages. All pairwise differences in redemption rates were significant (p<0·01) after correction for multiple comparisons. Targeting nominated friends increased adoption of the nutritional intervention by 12·2% compared with random targeting (95% CI 6·9-17·9). Targeting the most highly connected individuals, by contrast, produced no greater adoption of either intervention, compared with random targeting.

INTERPRETATION

Introduction of a health intervention to the nominated friends of random individuals can enhance that intervention's diffusion by exploiting intrinsic properties of human social networks. This method has the additional advantage of scalability because it can be implemented without mapping the network. Deployment of certain types of health interventions via network targeting, without increasing the number of individuals targeted or the resources used, could enhance the adoption and efficiency of those interventions, thereby improving population health.

FUNDING

National Institutes of Health, The Bill & Melinda Gates Foundation, Star Family Foundation, and the Canadian Institutes of Health Research.

A systematic review of state and manufacturer physician payment disclosure websites: implications for implementation of the Sunshine Act

Under the Physician Payment Sunshine Act (PPSA), payments to physicians from pharmaceutical, biologics, and medical device manufacturers will be disclosed on a national, publicly available website. To inform the development of the federal website, we evaluated 21 existing state and industry disclosure websites. The presentation formats and language used suggest that industry websites are aimed at patient audiences whereas state websites are structured to transmit data to researchers and guide compliance officers. These findings raise questions about the intended audience and aims of the PPSA disclosure database and expected outcomes of the law. Based on our evaluation, we offer recommendations for the national website and discuss implications of this policy for the health care system.

High-frequency afferent stimulation induces long-term potentiation of field potentials in the ventral tegmental area

Excitatory synapses on dopamine neurons in the VTA can undergo both long-term potentiation and depression. Additionally, drug-induced plasticity has been found at VTA synapses, and is proposed to play a role in reward-related learning and addiction by modifying dopamine cell firing. LTP at these synapses is difficult to generate experimentally in that it requires an undisturbed intracellular milieu and is often small in magnitude. Here, we demonstrate the induction of LTP as a property of evoked field potentials within the VTA. Excitatory field potentials were recorded extracellularly from VTA neurons in acute horizontal midbrain slices. Using extracellular and intracellular recording techniques, we found that evoked field potentials originate within the VTA itself and are largely composed of AMPA receptor-mediated EPSPs and action potentials triggered by activation of glutamatergic synapses on both dopamine and GABA neurons. High-frequency afferent stimulation (HFS) induced LTP of the field potential. The induction of this LTP was blocked by application of the NMDAR antagonist, d-APV, prior to HFS. As reported previously, glutamatergic synapses on GABA neurons did not express LTP while those on dopamine neurons did. We conclude that the potentiation of glutamatergic synapses on dopamine neurons is a major contributor to NMDA receptor-dependent LTP of the field potential. Field potential recordings may provide a convenient approach to explore the basic electrophysiological properties of VTA neurons and the development of addiction-related processes in this brain region.