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Mak J, Shires DA, Zhang Q, Prieto LR, Ahmedani BK, Kattari L, Becerra-Culqui TA, Bradlyn A, Flanders WD, Getahun D, Giammattei SV, Hunkeler EM, Lash TL, Nash R, Quinn VP, Robinson B, Roblin D, Silverberg MJ, Slovis J, Tangpricha V, Vupputuri S, Goodman M. Suicide Attempts Among a Cohort of Transgender and Gender Diverse People. Am J Prev Med 2020; 59:570-577. [PMID: 32798005 PMCID: PMC7508867 DOI: 10.1016/j.amepre.2020.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Transgender and gender diverse people often face discrimination and may experience disproportionate emotional distress that leads to suicide attempts. Therefore, it is essential to estimate the frequency and potential determinants of suicide attempts among transgender and gender diverse individuals. METHODS Longitudinal data on 6,327 transgender and gender diverse individuals enrolled in 3 integrated healthcare systems were analyzed to assess suicide attempt rates. Incidence was compared between transmasculine and transfeminine people by age and race/ethnicity and according to mental health status at baseline. Cox proportional hazards models examined rates and predictors of suicide attempts during follow-up. Data were collected in 2016, and analyses were conducted in 2019. RESULTS During follow-up, 4.8% of transmasculine and 3.0% of transfeminine patients had at least 1 suicide attempt. Suicide attempt rates were more than 7 times higher among patients aged <18 years than among those aged >45 years, more than 3 times higher among patients with previous history of suicide ideation or suicide attempts than among those with no such history, and 2-5 times higher among those with 1-2 mental health diagnoses and more than 2 mental health diagnoses at baseline than among those with none. CONCLUSIONS Among transgender and gender diverse individuals, younger people, people with previous suicidal ideation or attempts, and people with multiple mental health diagnoses are at a higher risk for suicide attempts. Future research should examine the impact of gender-affirming healthcare use on the risk of suicide attempts and identify targets for suicide prevention interventions among transgender and gender diverse people in clinical settings.
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Affiliation(s)
- Josephine Mak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Deirdre A Shires
- School of Social Work, Michigan State University, East Lansing, Michigan; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan.
| | - Qi Zhang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lucas R Prieto
- School of Social Work, Michigan State University, East Lansing, Michigan
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Leonardo Kattari
- School of Social Work, Michigan State University, East Lansing, Michigan
| | - Tracy A Becerra-Culqui
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Andrew Bradlyn
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - W Dana Flanders
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Shawn V Giammattei
- The Rockway Institute, Alliant International University, San Francisco, California
| | - Enid M Hunkeler
- Division of Research, Kaiser Permanente, Northern California (emerita), Oakland, California
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Virginia P Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California (emerita), Pasadena, California
| | - Brandi Robinson
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, Maryland
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Jennifer Slovis
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Vin Tangpricha
- School of Medicine, Emory University, Atlanta, Georgia; The Atlanta VA Medical Center, Atlanta, Georgia
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, Maryland
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Coleman KJ, Yarborough BJ, Beck A, Lynch FL, Stewart C, Penfold RS, Hunkeler EM, Operskalski BH, Simon GE. Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups. Ethn Dis 2019; 29:609-616. [PMID: 31641328 PMCID: PMC6802164 DOI: 10.18865/ed.29.4.609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Objective To compare patterns of health care utilization associated with first presentation of psychosis among different racial and ethnic groups of patients. Design The study was a retrospective observational design. Setting The study was conducted in five health care systems in the western United States. All sites were also part of the National Institute of Mental Health-funded Mental Health Research Network (MHRN). Participants Patients (n = 852) were aged 15 - 59 years (average 26.9 ± 12.2 years), 45% women, and primarily non-Hispanic White (53%), with 16% Hispanic, 10% non-Hispanic Black, 6% Asian, 1% Native Hawaiian/Pacific Islander, 1% Native American/ Alaskan Native, and 12% unknown race/ethnicity. Main Outcome Measures Variables examined were patterns of health care utilization, type of comorbid mental health condition, and type of treatment received in the three years before first presentation of psychosis. Methods Data abstracted from electronic medical records and insurance claims data were organized into a research virtual data warehouse (VDW) and used for analysis. Results Compared with non-Hispanic Whites, Asian patients (16% vs 34%; P=.007) and non-Hispanic Black patients (20% vs 34%; P=.009) were less likely to have a visit with specialty mental health care before their first presentation of psychosis. Conclusions Early detection of first episode psychosis should start with wider screening for symptoms outside of any indicators for mental health conditions for non-Hispanic Black and Asian patients.
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Affiliation(s)
- Karen J. Coleman
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA
| | | | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO
| | - Frances L. Lynch
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | | | | | - Enid M. Hunkeler
- Kaiser Permanente Northern California Division of Research (Emeritus), Oakland, CA
| | | | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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Gerth J, Becerra-Culqui T, Bradlyn A, Getahun D, Hunkeler EM, Lash TL, Millman A, Nash R, Quinn VP, Robinson B, Roblin D, Silverberg MJ, Tangpricha V, Vupputuri S, Goodman M. Agreement between medical records and self-reports: Implications for transgender health research. Rev Endocr Metab Disord 2018; 19:263-269. [PMID: 30219985 PMCID: PMC6438197 DOI: 10.1007/s11154-018-9461-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A key priority of transgender health research is the evaluation of long-term effects of gender affirmation treatment. Thus, accurate assessment of treatment receipt is critical. The data for this analysis came from an electronic medical records (EMR) based cohort of transgender individuals. A subset of cohort members were also asked to complete a self-administered survey. Information from the EMR was compared with survey responses to assess the extent of agreement regarding transmasculine (TM)/transfeminine (TF) status, hormone therapy receipt, and type of surgery performed. Logistic regression models were used to assess whether participant characteristics were associated with disagreement between data sources. Agreement between EMR and survey-derived information was high regarding TM/TF status (99%) and hormone therapy receipt (97%). Lower agreement was observed for chest reconstruction surgery (72%) and genital reconstruction surgery (84%). Using survey responses as the "gold standard", both chest and genital reconstruction surgeries had high specificity (95 and 93%, respectively), but the corresponding sensitivities were low (49 and 68%, respectively). A lower proportion of TM had concordant results for chest reconstruction surgery (64% versus 79% for TF) while genital reconstruction surgery concordance was lower among TF (79% versus 89% for TM). For both surgery types, agreement was highest among the youngest participants. Our findings offer assurance that EMR-based data appropriately classify cohort participants with respect to their TM/TF status or hormone therapy receipt. However, current EMR data may not capture the complete history of gender affirmation surgeries. This information is useful in future studies of outcomes related to gender affirming therapy.
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Affiliation(s)
- Joseph Gerth
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, CNR 3021, Atlanta, GA, 30322, USA
| | - Tracy Becerra-Culqui
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Andrew Bradlyn
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Enid M Hunkeler
- Emerita, Division of Research, Kaiser Permanente, Northern California, Oakland, CA, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, CNR 3021, Atlanta, GA, 30322, USA
| | - Andrea Millman
- Division of Research, Kaiser Permanente, Northern California, Oakland, CA, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, CNR 3021, Atlanta, GA, 30322, USA
| | - Virginia P Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | | | - Vin Tangpricha
- School of Medicine, Emory University, Atlanta, GA, USA
- The Atlanta VA Medical Center, Atlanta, GA, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, CNR 3021, Atlanta, GA, 30322, USA.
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Becerra-Culqui TA, Liu Y, Nash R, Cromwell L, Flanders WD, Getahun D, Giammattei SV, Hunkeler EM, Lash TL, Millman A, Quinn VP, Robinson B, Roblin D, Sandberg DE, Silverberg MJ, Tangpricha V, Goodman M. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics 2018; 141:e20173845. [PMID: 29661941 PMCID: PMC5914494 DOI: 10.1542/peds.2017-3845] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions. METHODS Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3-9 years old) and adolescents (10-17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date. RESULTS Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4-82) to 144 (95% CI 36-1248). The corresponding range for suicidal ideation was 25 (95% CI 14-45) to 54 (95% CI 18-218). CONCLUSIONS TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.
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Affiliation(s)
- Tracy A Becerra-Culqui
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Yuan Liu
- Departments of Biostatistics and Bioinformatics and
| | - Rebecca Nash
- Epidemiology, Rollins School of Public Health, and
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia
| | | | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Shawn V Giammattei
- Rockway Institute, Alliant International University, San Francisco, California
| | - Enid M Hunkeler
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | | | - Andrea Millman
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Virginia P Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland
| | - David E Sandberg
- Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan; and
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Vin Tangpricha
- Emory School of Medicine, Emory University, Atlanta, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
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Simon GE, Stewart C, Hunkeler EM, Yarborough BJ, Lynch F, Coleman KJ, Beck A, Operskalski BH, Penfold RS, Carrell DS. Care Pathways Before First Diagnosis of a Psychotic Disorder in Adolescents and Young Adults. Am J Psychiatry 2018; 175:434-442. [PMID: 29361848 PMCID: PMC5930077 DOI: 10.1176/appi.ajp.2017.17080844] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors sought to describe patterns of health care use prior to first diagnosis of a psychotic disorder in a population-based sample. METHOD Electronic health records and insurance claims from five large integrated health systems were used to identify 624 patients 15-29 years old who received a first diagnosis of a psychotic disorder in any care setting and to record health services received, diagnoses assigned, and medications dispensed during the previous 36 months. Patterns of utilization were compared between patients receiving a first diagnosis of a psychotic disorder and matched samples of general health system members and members receiving a first diagnosis of unipolar depression. RESULTS During the year before a first psychotic disorder diagnosis, 29% of patients had mental health specialty outpatient care, 8% had mental health inpatient care, 24% had emergency department mental health care, 29% made a primary care visit with a mental health diagnosis, and 60% received at least one mental health diagnosis (including substance use disorders). Compared with patients receiving a first diagnosis of unipolar depression, those with a first diagnosis of a psychotic disorder were modestly more likely to use all types of health services and were specifically more likely to use mental health inpatient care (odds ratio=2.96, 95% CI=1.97-4.43) and mental health emergency department care (rate ratio=3.74, 95% CI=3.39-4.53). CONCLUSIONS Most patients receiving a first diagnosis of a psychotic disorder had some indication of mental health care need during the previous year. General use of primary care or mental health services, however, does not clearly distinguish people who later receive a diagnosis of a psychotic disorder from those who later receive a diagnosis of unipolar depression. Use of inpatient or emergency department mental health care is a more specific indicator of risk.
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Affiliation(s)
- Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | - Enid M Hunkeler
- Kaiser Permanente Northern California Division of Research (Emeritus), Oakland, CA
| | | | - Frances Lynch
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | - Karen J Coleman
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO
| | | | - Robert S Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - David S Carrell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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Simon GE, Stewart C, Yarborough BJ, Lynch F, Coleman KJ, Beck A, Operskalski BH, Penfold RB, Hunkeler EM. Mortality Rates After the First Diagnosis of Psychotic Disorder in Adolescents and Young Adults. JAMA Psychiatry 2018; 75:254-260. [PMID: 29387876 PMCID: PMC5885951 DOI: 10.1001/jamapsychiatry.2017.4437] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Individuals with psychotic disorders have increased mortality, and recent research suggests a marked increase shortly after diagnosis. OBJECTIVE To use population-based data to examine overall and cause-specific mortality after first diagnosis of a psychotic disorder. DESIGN, SETTING, AND PARTICIPANTS This cohort study used records from 5 integrated health systems that serve more than 8 million members in 5 states. Members aged 16 through 30 years who received a first lifetime diagnosis of a psychotic disorder from September 30, 2009, through September 30, 2015, and 2 comparison groups matched for age, sex, health system, and year of diagnosis were selected from all members making an outpatient visit (general outpatient group) and from all receiving a first diagnosis of unipolar depression (unipolar depression group). EXPOSURES First recorded diagnosis of schizophrenia, schizoaffective disorder, mood disorder with psychotic symptoms, or other psychotic disorder in any outpatient, emergency department, or inpatient setting. MAIN OUTCOMES AND MEASURES Death within 3 years after the index diagnosis or visit date, ascertained from health system electronic health records, insurance claims, and state mortality records. RESULTS A total of 11 713 members with first diagnosis of a psychotic disorder (6976 [59.6%] men and 4737 [40.4%] women; 2368 [20.2%] aged 16-17 and 9345 [79.8%] aged 18-30 years) were matched to 35 576 outpatient service users and 23 415 members with a first diagnosis of unipolar depression. During the year after the first diagnosis, all-cause mortality was 54.6 (95% CI, 41.3-68.0) per 10 000 in the psychotic disorder group compared with 20.5 (95% CI, 14.7-26.3) per 10 000 in the unipolar depression group and 6.7 (95% CI, 4.0-9.4) per 10 000 in the general outpatient group. After adjustment for race, ethnicity, and preexisting chronic medical conditions, the relative hazard of death in the psychotic disorder group compared with the general outpatient group was 34.93 (95% CI, 8.19-149.10) for self-inflicted injury or poisoning and 4.67 (95% CI, 2.01-10.86) for other type of injury or poisoning. Risk of death due to heart disease or diabetes did not differ significantly between the psychotic disorder and the general outpatient groups (hazard ratio, 0.78; 95% CI, 0.15-3.96). Between the first and third years after diagnosis, all-cause mortality in the psychotic disorder group decreased from 54.6 to 27.1 per 10 000 persons and injury and poisoning mortality decreased from 30.6 to 15.1 per 10 000 persons. Both rates, however, remained 3 times as high as in the general outpatient group (9.0 per 10 000 for all causes; 4.8 per 10 000 for injury or poisoning). CONCLUSIONS AND RELEVANCE Increases in early mortality underscore the importance of systematic intervention for young persons experiencing the first onset of psychosis. Clinicians should attend to the elevated suicide risk after the first diagnosis a psychotic disorder.
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Affiliation(s)
- Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Christine Stewart
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Frances Lynch
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Karen J. Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
| | | | - Robert B. Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Enid M. Hunkeler
- Division of Research (Emeritus), Kaiser Permanente Northern California, Oakland
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Simon GE, Coleman KJ, Yarborough BJH, Operskalski B, Stewart C, Hunkeler EM, Lynch F, Carrell D, Beck A. First Presentation With Psychotic Symptoms in a Population-Based Sample. Psychiatr Serv 2017; 68:456-461. [PMID: 28045349 PMCID: PMC5811263 DOI: 10.1176/appi.ps.201600257] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Increasing evidence supports the effectiveness of comprehensive early intervention at first onset of psychotic symptoms. Implementation of early intervention programs will require population-based data on overall incidence of psychotic symptoms and on care settings of first presentation. METHODS In five large health care systems, electronic health records data were used to identify all first occurrences of psychosis diagnoses among persons ages 15-59 between January 1, 2007, and December 31, 2013 (N=37,843). For a random sample of these putative cases (N=1,337), review of full-text medical records confirmed clinician documentation of psychotic symptoms and excluded those with documented prior diagnosis of or treatment for psychosis. Initial incidence rates (based on putative cases) and confirmation rates (from record reviews) were used to estimate true incidence according to age and setting of initial presentation. RESULTS Annual incidence estimates based on putative cases were 126 per 100,000 among those ages 15-29 and 107 per 100,000 among those ages 30-59. Rates of chart review confirmation ranged from 84% among those ages 15-29 diagnosed in emergency department or inpatient mental health settings to 19% among those ages 30-59 diagnosed in general medical outpatient settings. Estimated true incidence rates were 86 per 100,000 per year among those ages 15-29 and 46 per 100,000 among those ages 30-59. CONCLUSIONS When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimates based on surveys or inpatient data. Early intervention programs must accommodate frequent presentation after age 30 and presentation in outpatient settings, including primary care.
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Affiliation(s)
- Gregory E Simon
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Karen J Coleman
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Bobbi Jo H Yarborough
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Belinda Operskalski
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Christine Stewart
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Enid M Hunkeler
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Frances Lynch
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - David Carrell
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
| | - Arne Beck
- Dr. Simon, Ms. Operskalski, Dr. Stewart, and Dr. Carrell are with the Group Health Research Institute, Group Health Cooperative, Seattle (e-mail: ). Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Yarborough and Dr. Lynch are with the Center for Health Research, Kaiser Permanente, Portland, Oregon. When this work was done, Ms. Hunkeler, who is now retired, was with the Division of Research, Kaiser Permanente, Oakland, California. Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver
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Owen-Smith AA, Woodyatt C, Sineath RC, Hunkeler EM, Barnwell LT, Graham A, Stephenson R, Goodman M. Perceptions of Barriers to and Facilitators of Participation in Health Research Among Transgender People. Transgend Health 2016; 1:187-196. [PMID: 28861532 PMCID: PMC5549538 DOI: 10.1089/trgh.2016.0023] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Although transgender people may be at increased risk for a range of health problems, they have been the subject of relatively little health research. An important step toward expanding the evidence base is to understand and address the reasons for nonparticipation and dropout. The aim of this study was to explore the perceptions of barriers to and facilitators of participation in health research among a sample of transgender people in San Francisco, CA, and Atlanta, GA. Methods: Twelve in-person focus groups (FGs) were conducted; six (three with transwomen, three with transmen) were conducted in San Francisco and six FGs were conducted in Atlanta (three with transwomen and three with transmen). FGs were audiorecorded, transcribed, and uploaded to MaxQDA software for analysis. A codebook was used to code transcripts; new codes were added iteratively as they arose. All transcripts were coded by at least 2 of the 4 researchers and, after each transcript was coded, the researchers met to discuss any discrepancies, which were resolved by consensus. Results: Among 67 FG participants, 37 (55%) identified as transmen and 30 (45%) identified as transwomen. The average age of participants was ∼41 years (range 18-67) and the majority (61%) were non-Hispanic Whites. Several barriers that can hinder participation in health research were identified, including logistical concerns, issues related to mistrust, a lack of awareness about participation opportunities, and psychosocial/emotional concerns related to being "outed." A broad range of facilitators were also identified, including the opportunity to gain knowledge, access medical services, and contribute to the transgender community. Conclusion: These findings provide insights about the perceived barriers to and facilitators of research participation and offer some guidance for researchers in our ongoing effort to engage the transgender community in health research.
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Affiliation(s)
- Ashli A Owen-Smith
- Department of Health Management and Policy, School of Public Health, Georgia State University, Atlanta, Georgia
| | - Cory Woodyatt
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - R Craig Sineath
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Enid M Hunkeler
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - La Tasha Barnwell
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ashley Graham
- Department of Anthropology, University of Connecticut, Storrs, Connecticut
| | - Rob Stephenson
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Owen-Smith AA, Sineath C, Sanchez T, Dea R, Giammattei S, Gillespie T, Helms MF, Hunkeler EM, Quinn VP, Roblin D, Slovis J, Stephenson R, Sullivan PS, Tangpricha V, Woodyatt C, Goodman M. Perception of Community Tolerance and Prevalence of Depression among Transgender Persons. J Gay Lesbian Ment Health 2016; 21:64-76. [PMID: 29170689 DOI: 10.1080/19359705.2016.1228553] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose The goal of the study was to examine the association between depression and perceived community tolerance after controlling for various demographic and personal characteristics, treatment receipt, and past experiences with abuse or discrimination. Methods An on-line survey assessed depressive symptoms among transgender and gender non-conforming individuals. Depression was assessed using the 7-item Beck Depression Inventory for Primary Care (BDI-PC) and the 10-item Center for Epidemiologic Studies Depression (CESD-10) scale. Results The prevalence ratios (95% confidence intervals) comparing depression in persons who did and did not perceive their area as tolerant were 0.33 (0.20-0.54) for BD-PC and 0.66 (0.49-0.89) for CESD-10. Other factors associated with depression were experience with abuse or discrimination, lower education, and unfulfilled desire to receive hormonal therapy. Conclusion Depression was common in this sample of transgender and gender non-conforming individuals and was strongly and consistently associated with participants' perceptions of community tolerance, even after adjusting for possible confounding. The association between desire to receive hormonal therapy and depression is a finding that warrants further exploration. Future research should also assess depression and changes in perception of community tolerance in transgender individuals before and after initiation of gender confirmation treatment.
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Affiliation(s)
- Ashli A Owen-Smith
- Georgia State University, School of Public Health, Department of Health Management and Policy, Atlanta GA
| | - Craig Sineath
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
| | - Travis Sanchez
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
| | - Robin Dea
- The Permanente Medical Group (Retired), Redwood City, CA
| | - Shawn Giammattei
- The Rockway Institute, Alliant International University, San Francisco, CA
| | - Theresa Gillespie
- Emory University, School of Medicine, Department of Surgery, Atlanta, GA
| | - Monica F Helms
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
| | - Enid M Hunkeler
- Kaiser Permanente Northern California, Division of Research, Oakland, CA
| | | | - Douglas Roblin
- Georgia State University, School of Public Health, Department of Health Management and Policy, Atlanta GA
| | - Jennifer Slovis
- Kaiser Permanente Northern California, Division of Research, Oakland, CA
| | - Robert Stephenson
- University of Michigan, School of Nursing, Department of Health Behavior and Biological Sciences, Ann Arbor, MI
| | - Patrick S Sullivan
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
| | - Vin Tangpricha
- Emory University, School of Medicine, Department of Endocrinology, Atlanta, GA
| | - Cory Woodyatt
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
| | - Michael Goodman
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta GA
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Coleman KJ, Stewart C, Waitzfelder BE, Zeber JE, Morales LS, Ahmed AT, Ahmedani BK, Beck A, Copeland LA, Cummings JR, Hunkeler EM, Lindberg NM, Lynch F, Lu CY, Owen-Smith AA, Trinacty CM, Whitebird RR, Simon GE. Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network. Psychiatr Serv 2016; 67:749-57. [PMID: 27079987 PMCID: PMC4930394 DOI: 10.1176/appi.ps.201500217] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems. METHODS Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings. RESULTS Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64). CONCLUSIONS There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.
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Affiliation(s)
- Karen J Coleman
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Christine Stewart
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Beth E Waitzfelder
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - John E Zeber
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Leo S Morales
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Ameena T Ahmed
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Brian K Ahmedani
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Arne Beck
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Laurel A Copeland
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Janet R Cummings
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Enid M Hunkeler
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Nangel M Lindberg
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Frances Lynch
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Christine Y Lu
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Ashli A Owen-Smith
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Connie Mah Trinacty
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Robin R Whitebird
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
| | - Gregory E Simon
- Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (e-mail: ). Dr. Stewart and Dr. Simon are with the Group Health Research Institute, Group Health Cooperative, Seattle. Dr. Waitzfelder and Dr. Trinacty are with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Zeber and Dr. Copeland are with Health Services Research and Development, U.S. Department of Veterans Affairs, Temple, Texas, and the Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas. Dr. Morales is with the Center for Health Equity, Diversity and Inclusion, University of Washington, Seattle. Dr. Ahmed is with Kaiser Permanente Northern California, Permanente Medical Group, San Francisco. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit. Dr. Beck is with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Cummings is with the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland. Dr. Lindberg and Dr. Lynch are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. Dr. Owen-Smith is with the School of Public Health, Georgia State University, Atlanta. Dr. Whitebird is with the School of Social Work, University of St. Thomas/St. Catherine University, St. Paul, Minnesota
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11
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Atkins L, Hunkeler EM, Jensen CD, Michie S, Lee JK, Doubeni CA, Zauber AG, Levin TR, Quinn VP, Corley DA. Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement. Gastrointest Endosc 2016; 83:617-26.e2. [PMID: 26366787 PMCID: PMC4762744 DOI: 10.1016/j.gie.2015.08.075] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Interventions to improve physician adenoma detection rates for colonoscopy have generally not been successful, and there are little data on the factors contributing to variation that may be appropriate targets for intervention. We sought to identify factors that may influence variation in detection rates by using theory-based tools for understanding behavior. METHODS We separately studied gastroenterologists and endoscopy nurses at 3 Kaiser Permanente Northern California medical centers to identify potentially modifiable factors relevant to physician adenoma detection rate variability by using structured group interviews (focus groups) and theory-based tools for understanding behavior and eliciting behavior change: the Capability, Opportunity, and Motivation behavior model; the Theoretical Domains Framework; and the Behavior Change Wheel. RESULTS Nine factors potentially associated with adenoma detection rate variability were identified, including 6 related to capability (uncertainty about which types of polyps to remove, style of endoscopy team leadership, compromised ability to focus during an examination due to distractions, examination technique during withdrawal, difficulty detecting certain types of adenomas, and examiner fatigue and pain), 2 related to opportunity (perceived pressure due to the number of examinations expected per shift and social pressure to finish examinations before scheduled breaks or the end of a shift), and 1 related to motivation (valuing a meticulous examination as the top priority). Examples of potential intervention strategies are provided. CONCLUSIONS By using theory-based tools, this study identified several novel and potentially modifiable factors relating to capability, opportunity, and motivation that may contribute to adenoma detection rate variability and be appropriate targets for future intervention trials.
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Affiliation(s)
- Louise Atkins
- Centre for Behaviour Change, University College London, London, England
| | | | | | - Susan Michie
- Centre for Behaviour Change, University College London, London, England
| | | | - Chyke A. Doubeni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research and Evaluation, Pasadena, CA
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12
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Lu CY, Stewart C, Ahmed AT, Ahmedani BK, Coleman K, Copeland LA, Hunkeler EM, Lakoma MD, Madden JM, Penfold RB, Rusinak D, Zhang F, Soumerai SB. How complete are E-codes in commercial plan claims databases? Pharmacoepidemiol Drug Saf 2014; 23:218-20. [PMID: 24453020 DOI: 10.1002/pds.3551] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 10/08/2013] [Accepted: 10/28/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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13
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Simon GE, Stewart C, Beck A, Ahmedani BK, Coleman KJ, Whitebird RR, Lynch F, Owen-Smith AA, Waitzfelder BE, Soumerai SB, Hunkeler EM. National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis. Psychiatr Serv 2014; 65:944-6. [PMID: 24788368 PMCID: PMC4216631 DOI: 10.1176/appi.ps.201300371] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study addressed recent concerns regarding increasing prescription of antidepressant drugs to patients with no recorded psychiatric diagnosis. METHODS Records from ten large integrated health systems in the Mental Health Research Network were used to examine diagnoses received by 1,011,946 health plan members who filled at least one antidepressant prescription in 2010. RESULTS Among individuals filling antidepressant prescriptions, psychiatric diagnoses recorded during the year were depressive disorders (48%), anxiety disorders (27%), bipolar disorders (3%), and attention deficit disorders (3%). The proportion of those filling prescriptions who had no psychiatric diagnosis was 39%, which fell to 27% after the analysis excluded prescriptions for antidepressants often prescribed for nonpsychiatric indications (tricyclic antidepressants, trazodone, and bupropion). CONCLUSIONS Prescription of antidepressants to patients without an appropriate diagnosis appears to be less common than previously reported.
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Affiliation(s)
- Gregory E Simon
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Christine Stewart
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Arne Beck
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Brian K Ahmedani
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Karen J Coleman
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Robin R Whitebird
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Frances Lynch
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Ashli A Owen-Smith
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Beth E Waitzfelder
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Stephen B Soumerai
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
| | - Enid M Hunkeler
- Dr. Simon and Dr. Stewart are with the Group Health Research Institute, Group Health Cooperative, Seattle, Washington (e-mail: ). Dr. Beck is with the Institute for Health Research, Kaiser Permanente of Colorado, Denver. Dr. Ahmedani is with the Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan. Dr. Coleman is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. Dr. Whitebird is with HealthPartners Institute for Education and Research, Minneapolis, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Owen-Smith is with the Center for Health Research, Kaiser Permanente Georgia, Atlanta. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Soumerai is with the Department of Population Medicine, Harvard Medical School, Boston. Ms. Hunkeler is with the Division of Research, Kaiser Permanente Northern California, Oakland
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14
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Lu CY, Zhang F, Lakoma MD, Madden JM, Rusinak D, Penfold RB, Simon G, Ahmedani BK, Clarke G, Hunkeler EM, Waitzfelder B, Owen-Smith A, Raebel MA, Rossom R, Coleman KJ, Copeland LA, Soumerai SB. Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. BMJ 2014; 348:g3596. [PMID: 24942789 PMCID: PMC4062705 DOI: 10.1136/bmj.g3596] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people. DESIGN Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends. SETTING Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network. PARTICIPANTS Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million). MAIN OUTCOME MEASURES Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides. RESULTS Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group. CONCLUSIONS Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.
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Affiliation(s)
- Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Matthew D Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Jeanne M Madden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Donna Rusinak
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Robert B Penfold
- Group Health Research Institute, Seattle, WA, USA Department of Health Services Research, University of Washington, Seattle, WA, USA
| | - Gregory Simon
- Group Health Research Institute, Seattle, WA, USA Mental Health Research Network
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Enid M Hunkeler
- The Division of Research, Kaiser Permanente Medical Care Program Northern California, Oakland, CA, USA
| | - Beth Waitzfelder
- Kaiser Permanente Center for Health Research Hawaii, Honolulu, HI, USA
| | - Ashli Owen-Smith
- The Center for Health Research Southeast, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
| | - Rebecca Rossom
- HealthPartners Institute for Education and Research, Bloomington, MN, USA
| | - Karen J Coleman
- Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, CA, USA
| | - Laurel A Copeland
- Center for Applied Health Research, Central Texas Veterans Health Care System jointly with Scott & White Healthcare, Temple, TX, USA
| | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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15
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Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, Lynch F, Owen-Smith A, Hunkeler EM, Whiteside U, Operskalski BH, Coffey MJ, Solberg LI. Health care contacts in the year before suicide death. J Gen Intern Med 2014; 29:870-7. [PMID: 24567199 PMCID: PMC4026491 DOI: 10.1007/s11606-014-2767-3] [Citation(s) in RCA: 381] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/23/2013] [Accepted: 12/20/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples. OBJECTIVE To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed. DESIGN Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states. PARTICIPANTS In all, 5,894 individuals who died by suicide, and were health plan members in the year before death. MAIN MEASURES Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site. KEY RESULTS Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means. CONCLUSIONS This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.
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Affiliation(s)
- Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, 1 Ford Place, 3A, Detroit, MI, 48202, USA,
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16
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Penfold RB, Stewart C, Hunkeler EM, Madden JM, Cummings J, Owen-Smith AA, Rossom RC, Lu C, Lynch FL, Waitzfelder BE, Coleman KA, Ahmedani BK, Beck AL, Zeber JE, Simon GE, Simon GE. Use of antipsychotic medications in pediatric populations: what do the data say? Curr Psychiatry Rep 2013; 15:426. [PMID: 24258527 PMCID: PMC4167011 DOI: 10.1007/s11920-013-0426-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.
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Affiliation(s)
- Robert B. Penfold
- Group Health Research Institute and Department of Health Services Research, University of Washington
| | | | | | - Jeanne M. Madden
- Harvard Pilgrim Health Care Research Institute and Department of Population
Medicine, Harvard University
| | - Janet Cummings
- Department of Health Policy and Management, Rollins School of Public Health
Emory University
| | | | - Rebecca C. Rossom
- Health Partners Institute for Education and Research and Department of
Psychiatry, University of Minnesota
| | - Christine Lu
- Harvard Pilgrim Health Care Research Institute and Department of Population
Medicine, Harvard University
| | | | | | - Karen A. Coleman
- Kaiser Permanente Center for Health Research, Southern California
| | | | - Arne L. Beck
- Kaiser Permanente Institute for Health Research, Colorado
| | - John E. Zeber
- Center for Applied Health Research, Scott and White Healthcare
| | - Greg E. Simon
- Group Health Research Institute and Department of Psychiatry, University of
Washington
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Hunkeler EM, Hargreaves WA, Fireman B, Terdiman J, Meresman JF, Porterfield Y, Lee J, Dea R, Simon GE, Bauer MS, Unützer J, Taylor CB. A web-delivered care management and patient self-management program for recurrent depression: a randomized trial. Psychiatr Serv 2012; 63:1063-71. [PMID: 22983558 DOI: 10.1176/appi.ps.005332011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study assessed the impact of an Internet-delivered care management and patient self-management program, eCare for Moods, on patients treated for recurrent or chronic depression. METHODS Patients with recurrent or chronic depression were randomly assigned to eCare (N=51) or usual specialty mental health care (N=52). The 12-month eCare program integrates with ongoing depression care, links to patients' electronic medical records, and provides clinicians with panel management and decision support. Participants were interviewed at baseline and six, 12, 18, and 24 months after enrollment. Telephone interviewers blind to treatment used a timeline follow-back method to estimate depression severity on a 6-point scale for each of the 105 study weeks (including the baseline). Differences between groups in weekly severity over two years were examined by generalized estimating equations. RESULTS Participants in eCare experienced more reduction in depressive symptoms (estimate=-.74 on the 6-point scale over two years; 95% confidence interval [CI]=-1.38 to -.09, p=.025) and were less often depressed (-.24 over two years; CI=-.46 to -.03, p=.026). At 24 months, 43% of eCare and 30% of usual-care participants were depression free; the number needed to treat to attain one additional depression-free participant was 8. eCare participants had other favorable outcomes: improved general mental health (p=.002), greater satisfaction with specialty care (p=.003) and with learning new coping skills (p<.001), and more confidence in managing depression (p=.006). CONCLUSIONS Internet-delivered care management can help improve outcomes of patients treated for recurrent or chronic depression.
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Affiliation(s)
- Enid M Hunkeler
- Division of Research, The Permanente Medical Group, Inc., 2000 Broadway, Second Floor, Oakland, CA 94612, USA.
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Arnow BA, Blasey CM, Hunkeler EM, Lee J, Hayward C. Does gender moderate the relationship between childhood maltreatment and adult depression? Child Maltreat 2011; 16:175-183. [PMID: 21727161 DOI: 10.1177/1077559511412067] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Although considerable evidence demonstrates that adults who report childhood maltreatment are at increased risk of depression in adulthood, little is known about whether gender moderates risk. In a sample of 5,673 adult Health Maintenance Organization (HMO) patients, the authors employed the Patient Health Questionnaire-8 (PHQ-8) to assess major depressive disorder (MDD) and the Childhood Trauma Questionnaire (CTQ) to assess five different types of childhood maltreatment: emotional, physical, and sexual abuse, as well as emotional and physical neglect. Logistic regression models tested the main and interactive effects of gender and childhood maltreatment. Consistent with previous studies, men and women with histories of each type of childhood adversity were significantly more likely to meet criteria for MDD. However, the authors found no evidence that gender moderates the risk of depression. These findings suggest that men and women reporting history of childhood maltreatment are equally likely to suffer major depression in adulthood.
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Affiliation(s)
- Bruce A Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, CA, USA.
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Arnow BA, Blasey CM, Lee J, Fireman B, Hunkeler EM, Dea R, Robinson R, Hayward C. Relationships among depression, chronic pain, chronic disabling pain, and medical costs. Psychiatr Serv 2009; 60:344-50. [PMID: 19252047 DOI: 10.1176/ps.2009.60.3.344] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although evidence suggests that patients with depression use more medical services than those without depression, few studies have examined whether specific subgroups of patients with depression have higher utilization than others. The study compared costs for general medical care with and without psychiatric care for patients with major depression and disabling chronic pain (reference group) with costs for five other groups: those with depression and nondisabling chronic pain, those with major depressive disorder alone, those with no depression who had disabling chronic pain, those with depression who had chronic pain that was not disabling, and those who had neither pain nor depression. Costs for the group with major depressive disorder alone were compared to costs for the three groups without depression. METHODS A questionnaire assessing major depressive disorder, chronic pain, and pain-related disability was mailed to a random sample of Kaiser Permanente patients who visited a primary care clinic. A total of 5,808 patients responded (54% participation rate). Costs for a two-year period were obtained from Kaiser Permanente's Cost Management Information System. Analyses were adjusted for presence of any of four major chronic medical illnesses. RESULTS Total costs for patients in the reference group were significantly higher than costs for the other five subgroups. Regression analyses indicated that continuous measures of severity of pain and severity of depression were associated with increased costs, but no statistically significant interaction of depression and pain on total cost was observed. CONCLUSIONS Patients with major depressive disorder and comorbid disabling chronic pain had higher medical service costs than other groups of patients with and without depression. However, findings suggest that the increases in cost from having both pain and depression are additive and not multiplicative.
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Affiliation(s)
- Bruce A Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94305-5722, USA.
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20
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Alexander JL, Richardson G, Grypma L, Hunkeler EM. Collaborative depression care, screening, diagnosis and specificity of depression treatments in the primary care setting. Expert Rev Neurother 2008; 7:S59-80. [PMID: 18039069 DOI: 10.1586/14737175.7.11s.s59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) program illustrates the relatively high rate of unremitted patients, regardless of clinical setting, who are receiving antidepressants. Nonmedication treatment approaches, referred to in the literature as 'nonsomatic treatments', for depression, anxiety and stress, include different forms of cognitive-behavioral therapy, interpersonal therapy, structured daily activities, mindfulness therapies, relaxation treatment protocols and exercise. The specificity of these treatments, their mechanisms of action, the motivation and time commitment required of patients, and the availability of trained practitioners to deliver them are reviewed. Midlife women with menopausal symptoms and depression/anxiety comorbidity represent a challenging patient population for whom an individualized treatment plan is often necessary. Treatment for depression comorbid with distressing menopausal symptoms would be facilitated by the implementation of a collaborative care program for depression in the primary care setting.
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Abstract
The authors conducted a retrospective cohort study of female patients diagnosed with breast cancer (BRCA), evaluating the risk of new-onset depression associated with tamoxifen treatment among those with estrogen receptor-positive (ER+) tumors, versus estrogen receptor-negative (ER-) tumors, who were not receiving tamoxifen. A total cohort of 2,943 patients was identified. The hazard-ratio for new-onset depression in the tamoxifen group was nonsignificant. A post-hoc analysis revealed that chemotherapy and ER+ status were significantly and independently associated with an increased risk for developing depression.
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Affiliation(s)
- Kelly C Lee
- Loma Linda Univ. School of Pharmacy, Loma Linda, CA 92350, USA.
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22
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Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino MJ, Fireman B, Kraemer HC, Dea R, Robinson R, Hayward C. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med 2006; 68:262-8. [PMID: 16554392 DOI: 10.1097/01.psy.0000204851.15499.fc] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together. METHODS A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate). RESULTS Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level. CONCLUSIONS Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.
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Affiliation(s)
- Bruce A Arnow
- Department of Psychiatry and Behavioral Sciences, University School of Medicine, Stanford, CA, USA.
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23
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Hunkeler EM, Katon W, Tang L, Williams JW, Kroenke K, Lin EHB, Harpole LH, Arean P, Levine S, Grypma LM, Hargreaves WA, Unützer J. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 2006; 332:259-63. [PMID: 16428253 PMCID: PMC1360390 DOI: 10.1136/bmj.38683.710255.be] [Citation(s) in RCA: 208] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the long term effectiveness of collaborative care management for depression in late life. DESIGN Two arm, randomised, clinical trial; intervention one year and follow-up two years. SETTING 18 primary care clinics in eight US healthcare organisations. Patients 1801 primary care patients aged 60 and older with major depression, dysthymia, or both. INTERVENTION Patients were randomly assigned to a 12 month collaborative care intervention (IMPACT) or usual care for depression. Teams including a depression care manager, primary care doctor, and psychiatrist offered education, behavioural activation, antidepressants, a brief, behaviour based psychotherapy (problem solving treatment), and relapse prevention geared to each patient's needs and preferences. MAIN OUTCOME MEASURES Interviewers, blinded to treatment assignment, conducted interviews in person at baseline and by telephone at each subsequent follow up. They measured depression (SCL-20), overall functional impairment and quality of life (SF-12), physical functioning (PCS-12), depression treatment, and satisfaction with care. RESULTS IMPACT patients fared significantly (P < 0.05) better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. One year after IMPACT resources were withdrawn, a significant difference in SCL-20 scores (0.23, P < 0.0001) favouring IMPACT patients remained. CONCLUSIONS Tailored collaborative care actively engages older adults in treatment for depression and delivers substantial and persistent long term benefits. Benefits include less depression, better physical functioning, and an enhanced quality of life. The IMPACT model may show the way to less depression and healthier lives for older adults.
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Affiliation(s)
- Enid M Hunkeler
- Kaiser Permanente, Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA.
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Katon W, Unützer J, Fan MY, Williams JW, Schoenbaum M, Lin EHB, Hunkeler EM. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006; 29:265-70. [PMID: 16443871 DOI: 10.2337/diacare.29.02.06.dc05-1572] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression. RESEARCH DESIGN AND METHODS This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care. RESULTS Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found. CONCLUSIONS The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care.
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Affiliation(s)
- Wayne Katon
- Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195-6560, USA.
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25
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Callahan CM, Kroenke K, Counsell SR, Hendrie HC, Perkins AJ, Katon W, Noel PH, Harpole L, Hunkeler EM, Unützer J. Treatment of Depression Improves Physical Functioning in Older Adults. J Am Geriatr Soc 2005; 53:367-73. [PMID: 15743276 DOI: 10.1111/j.1532-5415.2005.53151.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the effect of collaborative care management for depression on physical functioning in older adults. DESIGN Multisite randomized clinical trial. SETTING Eighteen primary care clinics from eight healthcare organizations. PARTICIPANTS One thousand eight hundred one patients aged 60 and older with major depressive disorder. INTERVENTION Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician. MEASUREMENTS The 12-item short form Physical Component Summary (PCS) score (range 0-100) and instrumental activities of daily living (IADLs) (range 0-7). RESULTS The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96-2.46) and IADLs of -0.15 (95% CI=-0.29 to -0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning. CONCLUSION The IMPACT collaborative care model for late-life depression improves physical function more than usual care.
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Hunkeler EM, Fireman B, Lee J, Diamond R, Hamilton J, He CX, Dea R, Nowell WB, Hargreaves WA. Trends in use of antidepressants, lithium, and anticonvulsants in Kaiser Permanente-insured youths, 1994-2003. J Child Adolesc Psychopharmacol 2005; 15:26-37. [PMID: 15741783 DOI: 10.1089/cap.2005.15.26] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In view of the current controversy regarding the use of antidepressants in children and adolescents, we examined trends from 1994 to 2003 in the use of antidepressants, lithium, and anticonvulsants by enrollees, aged 5-17 years, of Kaiser Permanente in Northern California. We found that the use of antidepressants more than doubled from 9.4 per 1000 enrollees to 21.3 per 1000. Most of this increase is associated with selective serotonin reuptake inhibitors (SSRIs), which increased from 4.6 to 14.5 per 1000. The use of tricyclic antidepressants (TCAs) decreased markedly, while the increase of other newer antidepressants rose from 1.3 to 6.5 per 1000. The use of anticonvulsants nearly doubled, from 3.5 to 6.9 per 1000, while lithium use was relatively stable at a rate of nearly 1 per 1000. Use of SSRIs, newer antidepressants, and anticonvulsants increased in boys as well as girls in each of three age groups: 5-9, 10-14, and 15-17 years. An increasing percentage of the antidepressant users had a diagnosis of depression, and an increasing percentage of anticonvulsant users had a diagnosis of bipolar disorder. Although the safety and efficacy of antidepressants in youths needs to be more firmly established, these findings may reflect progress in the diagnosis and treatment of mental illness.
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Affiliation(s)
- Enid M Hunkeler
- Kaiser Permanente, Division of Research, Oakland, California 94612, USA.
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27
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Hu XH, Bull SA, Hunkeler EM, Ming E, Lee JY, Fireman B, Markson LE. Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate. J Clin Psychiatry 2004; 65:959-65. [PMID: 15291685 DOI: 10.4088/jcp.v65n0712] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are widely used as the first-line treatment for depression. Information regarding their side effects is mostly based on controlled clinical trials. METHOD Patients who received an SSRI for a new or recurrent case of depression (ICD-9 code 296.2 or 311) between December 15, 1999, and May 31, 2000 were interviewed by telephone 75 to 105 days after initiation of SSRI therapy. Using closed-ended questions, investigators asked patients if they experienced any of 17 side effects commonly associated with SSRIs, how bothersome they were, and what their duration was. Prescribing physicians completed a written survey providing their estimates about frequency of side effects associated with SSRIs and how bothersome those side effects are. RESULTS Of 401 patients who completed the phone interview, 344 patients (86%) reported at least 1 side effect, and 219 patients (55%) experienced 1 or more bothersome side effect(s). The most common bothersome side effects were sexual dysfunction and drowsiness (17% each). While most side effects first occurred within the first 2 weeks of treatment, the majority of patients were still experiencing the same side effects at the time of interview, most notably blurred vision (85%) and sexual dysfunction (83%). Overall, physicians (N = 137) significantly underestimated the occurrence of the 17 side effects explored, and they tended to underrate how bothersome those side effects were to their patients. CONCLUSION Side effects associated with SSRIs are common and bothersome to patients. Treatment-emergent side effects tend to persist during the first 3 months of treatment.
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Affiliation(s)
- X Henry Hu
- Outcomes Research & Management, Merck & Co., Inc., West Point, PA 19486, USA.
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Abstract
CONTEXT Several studies have suggested that lithium treatment reduces risk of suicide in bipolar disorder, but no research has examined suicide risk during treatment with divalproex, the most commonly prescribed mood-stabilizing drug in the United States. OBJECTIVE To compare risk of suicide attempt and suicide death during treatment with lithium with that during treatment with divalproex. DESIGN AND SETTING Retrospective cohort study conducted at 2 large integrated health plans in California and Washington. PATIENTS Population-based sample of 20 638 health plan members aged 14 years or older who had at least 1 outpatient diagnosis of bipolar disorder and at least 1 filled prescription for lithium, divalproex, or carbamazepine between January 1, 1994, and December 31, 2001. Follow-up for each individual began with first qualifying prescription and ended with death, disenrollment from the health plan, or end of the study period. MAIN OUTCOME MEASURES Suicide attempt, recorded as a hospital discharge diagnosis or an emergency department diagnosis; suicide death, recorded on death certificate. RESULTS In both health plans, unadjusted rates were greater during treatment with divalproex than during treatment with lithium for emergency department suicide attempt (31.3 vs 10.8 per 1000 person-years; P<.001), suicide attempt resulting in hospitalization (10.5 vs 4.2 per 1000 person-years; P<.001), and suicide death (1.7 vs 0.7 per 1000 person-years; P =.04). After adjustment for age, sex, health plan, year of diagnosis, comorbid medical and psychiatric conditions, and concomitant use of other psychotropic drugs, risk of suicide death was 2.7 times higher (95% confidence interval [CI], 1.1-6.3; P =.03) during treatment with divalproex than during treatment with lithium. Corresponding hazard ratios for nonfatal attempts were 1.7 (95% CI, 1.2-2.3; P =.002) for attempts resulting in hospitalization and 1.8 (95% CI, 1.4-2.2; P<.001) for attempts diagnosed in the emergency department. CONCLUSION Among patients treated for bipolar disorder, risk of suicide attempt and suicide death is lower during treatment with lithium than during treatment with divalproex.
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Affiliation(s)
- Frederick K Goodwin
- Department of Psychiatry, George Washington University Medical Center, Washington, DC 20037, USA.
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29
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Abstract
More information is needed regarding the medical care utilization and costs of individuals who report depressed mood, persistent anxiety, brief anxiety, panic, and trouble controlling violent behavior. We present findings from a 1-year prospective follow-up study of a stratified random sample of adult HMO enrollees (N = 10,377) originally interviewed by telephone. A strong association was observed between these psychiatric symptoms, associated impaired function, and general medical care costs during the year following the interview. After controlling for age, gender, race, medical conditions, and smoking, the mean costs of general medical care were $1,948 for respondents who reported none of the psychiatric symptoms or impaired function: $3,006 for respondents with all 5 symptoms but no impaired function; and $3,906 for those with all 5 symptoms and pervasive functional impairment. Persistent anxiety and depressed mood had the greatest impact on total general medical costs, while impaired function was associated with increased likelihood of hospital admission and emergency room use. We conclude that depressed mood, persistent anxiety, and related impaired function are associated with substantial increases in the use and cost of general medical care.
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Affiliation(s)
- Enid M Hunkeler
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA.
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30
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Meresman JF, Hunkeler EM, Hargreaves WA, Kirsch AJ, Robinson P, Green A, Mann EZ, Getzell M, Feigenbaum P. A case report: implementing a nurse telecare program for treating depression in primary care. Psychiatr Q 2003; 74:61-73. [PMID: 12602789 DOI: 10.1023/a:1021145722959] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The treatment of depression in primary care needs improvement. Previously, we reported that a nurse telecare intervention for treating depression in primary care clinics significantly improved treatment outcomes. The usefulness of nurse telecare, however, depends upon the feasibility of dissemination. In this report we describe nurse telecare and the steps required for implementation, and describe its dissemination in various settings. In addition to medication, which is managed by a primary care physician, the key elements of nurse telecare are focused behavioral activation, emotional support, patient education, promotion of treatment adherence, and monitoring of progress, delivered in ten brief telephone appointments over four months by primary care nurses. Support from key administrators and clinical champions is crucial to success. Nurses need "dedicated" scheduled time for telecare activities. Nurse telecare has been piloted and disseminated in diverse settings. The model required only small modifications for dissemination, and was implemented with minimal investment of resources and no negative impact on clinic operations.
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Affiliation(s)
- Joel F Meresman
- Department of Psychiatry, Kaiser Permanente Medical Care Program, Northern California Region, Santa Clara, CA 95051, USA.
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31
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Oishi SM, Shoai R, Katon W, Callahan C, Unützer J, Arean P, Callahan C, Della Penna R, Harpole L, Hegel M, Noel PH, Hoffing M, Hunkeler EM, Katon W, Levine S, Lin EHB, Oddone E, Oishi S, Unützer J, Williams J. Impacting late life depression: integrating a depression intervention into primary care. Psychiatr Q 2003; 74:75-89. [PMID: 12602790 DOI: 10.1023/a:1021197807029] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
groups and semi-structured individual interviews with all Depression Clinical Specialists (DCSs) working with Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a study testing a collaborative care intervention for late life depression, to examine integration of the intervention model into primary care. DCSs described key intervention components, including supervision from a psychiatrist and a liaison primary care provider, weekly team meetings, computerized patient tracking, and outcomes assessment tools as effective in supporting patient care. DCSs discussed details of protocols, training, environmental set-up, and interpersonal factors that seemed to facilitate integration. DCSs also identified research-related factors that may need to be preserved in the real world. Basic elements of the IMPACT model seem to support integration of late life depression care into primary care. Research-related components may need modification for dissemination.
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Affiliation(s)
- Sabine M Oishi
- Center for Health Services Research, UCLA Neuropsychiatric Institute, 10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90024-7082, USA.
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Abstract
CONTEXT Although current depression treatment guidelines recommend continuing antidepressant therapy for at least 4 to 9 months, many patients discontinue treatment prematurely, within 3 months. OBJECTIVES To investigate the relationship between patient-physician communication and the continuation of treatment with antidepressants and to explore the demographics, adverse effects, therapeutic response, and frequency of follow-up visits. DESIGN, SETTING, AND PATIENTS A total of 401 telephone interviews of depressed patients being treated with selective serotonin reuptake inhibitor (SSRI) therapy between December 15, 1999, and May 31, 2000, were conducted and 137 prescribing physicians completed written surveys from Northern California Kaiser Permanente health maintenance organization outpatient clinics. MAIN OUTCOME MEASURES Patient-physician communication about therapy duration and about adverse effects; therapy discontinuation or medication switching within 3 months after start of SSRI therapy. RESULTS Ninety-nine physicians (72%) reported that they usually ask patients to continue using antidepressants for at least 6 months, but 137 patients (34%) reported that their physicians asked them to continue using antidepressants for this duration and 228 (56%) reported receiving no instructions. Patients who said they were told to take their medication for less than 6 months were 3 times more likely to discontinue therapy (odds ratio [OR], 3.12; 95% confidence interval [CI], 1.21-8.07) compared with patients who said they were told to continue therapy longer. Patients who discussed adverse effects with their physicians were less likely to discontinue therapy than patients who did not discuss them (OR, 0.49; 95% CI, 0.25-0.95). Patients who reported discussing adverse effects with their physicians were more likely to switch medications (OR, 5.60; 95% CI, 2.31-13.60). Fewer than 3 follow-up visits for depression, adverse effects, and lack of therapeutic response to medication were also associated with patients' discontinuing therapy. CONCLUSIONS Discrepancies exist between instructions that physicians report they communicate to patients and what patients remember being told. Explicit instructions about expected duration of therapy and discussions about medication adverse effects throughout treatment may reduce discontinuation of SSRI use. Our finding that patients with 3 or more follow-up visits were more likely to continue using the initially prescribed antidepressant medication suggests that frequent patient-physician contact may increase the probability that patients will continue therapy.
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Affiliation(s)
- Scott A Bull
- Division of Research, Kaiser Permanente Medical Care Program, 2000 Broadway, Oakland, CA 94612-2304, USA.
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Bull SA, Hunkeler EM, Lee JY, Rowland CR, Williamson TE, Schwab JR, Hurt SW. Discontinuing or switching selective serotonin-reuptake inhibitors. Ann Pharmacother 2002; 36:578-84. [PMID: 11918502 DOI: 10.1345/aph.1a254] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe reasons for discontinuing or switching selective serotonin-reuptake inhibitors (SSRIs) at 3 and 6 months after starting treatment, and to identify information provided to patients that may help prevent premature discontinuation of medication. METHODS Telephone surveys were conducted at 3 and 6 months after patients (n = 672) were started on an SSRI for a new or recurrent case of depression. RESULTS Significantly more patients discontinued or switched their SSRI because of an adverse effect within the first 3 months of starting (43%) compared with the second 3 months (27%; p = 0.023). The adverse effect most frequently reported as the reason for early discontinuation or switching was drowsiness/fatigue (10.2%), followed by anxiety, headache, and nausea - all at just over 5%. The odds ratio for discontinuation was 61% less in patients who recalled being told to take the medication for at least 6 months compared with those who did not (OR 0.39; p < 0.001). Patients who recalled being informed of potential adverse effects increased their reported incidence of mild to moderate adverse effects by 55% (OR 1.55; p < 0.05) without affecting rates of premature discontinuation (OR 1.06; p = 0.77). CONCLUSIONS Adverse effects are the most frequent reason for discontinuing or switching SSRIs within the first 3 months of treatment. Patients are more likely to continue taking their antidepressant if they fully understand how long to take the medication. Informing patients of potential adverse effects does not appear to prevent premature discontinuation, but may increase the patient's awareness and reporting of mild to moderate adverse effects.
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Affiliation(s)
- Scott A Bull
- The Permanente Medical Group Division of Research, Kaiser Permanente, Oakland, CA, USA
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Abstract
We examined the relationship between patterns of alcohol consumption and health care costs among adult members of the Kaiser Permanente Medical Care Program (KPMCP) in Northern California. A telephone survey of a random sample of the KPMCP membership aged 18 and over was conducted between June 1994 and February 1996 (n=10,175). The survey included questions on sociodemographic characteristics, general and mental health status, patterns of past and current alcohol consumption; inpatient and outpatient costs were obtained from Kaiser Permanentes cost management information system. Results showed that current non-drinkers with a history of heavy drinking had higher health costs than other non-drinkers and current drinkers. The per person per year costs for non-drinkers with a heavy drinking history were $2421 versus $1706 for other non-drinkers and $1358 for current drinkers in 1995 US dollars. A history of heavy drinking has a significant effect on costs after controlling for sociodemographic characteristics, health status and health practices. Current drinkers have the lowest costs, suggesting that they may be more likely than non-drinkers to delay seeking care until they are sick and require expensive medical care.
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Affiliation(s)
- E M Hunkeler
- Division of Research, Kaiser Permanente Medical Care Program, 3505 Broadway, 7th Floor, Oakland, CA 94611-5463, USA.
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Unützer J, Katon W, Williams JW, Callahan CM, Harpole L, Hunkeler EM, Hoffing M, Arean P, Hegel MT, Schoenbaum M, Oishi SM, Langston CA. Improving primary care for depression in late life: the design of a multicenter randomized trial. Med Care 2001; 39:785-99. [PMID: 11468498 DOI: 10.1097/00005650-200108000-00005] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. RESEARCH DESIGN A randomized controlled trial of a disease management program for late life depression. SUBJECTS Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. INTERVENTION Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient's regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. EVALUATION Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. CONCLUSIONS The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.
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Affiliation(s)
- J Unützer
- Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, CA, USA.
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36
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Weisner C, Mertens J, Parthasarathy S, Moore C, Hunkeler EM, Hu T, Selby JV. The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens. Health Serv Res 2000; 35:791-812. [PMID: 11055449 PMCID: PMC1089153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVE To compare outcome and cost-effectiveness of the two primary addiction treatment options, day hospitals (DH) and traditional outpatient programs (OP) in a managed care organization, in a population large enough to examine patient subgroups. DATA SOURCES Interviews with new admissions to a large HMO's chemical dependency program in Sacramento, California between April 1994 and April 1996, with follow-up interviews eight months later. Computerized utilization and cost data were collected from 1993 to 1997. STUDY DESIGN Design was a randomized control trial of adult patients entering the HMO's alcohol and drug treatment program (N = 668). To examine the generalizability of findings as well as self-selection factors, we also studied patients presenting during the same period who were unable or unwilling to be randomized (N = 405). Baseline interviews characterized type of substance use, addiction severity, psychiatric status, and motivation. Follow-up interviews were conducted at eight months following intake. Breathanalysis and urinalysis were conducted. Program costs were calculated. DATA COLLECTION Interview data were merged with computerized utilization and cost data. PRINCIPAL FINDINGS Among randomized subjects, both study arms showed significant improvement in all drug and alcohol measures. There were no differences overall in outcomes between DH and OP, but DH subjects with midlevel psychiatric severity had significantly better outcomes, particularly in regard to alcohol abstinence (OR = 2.4; 95% CI = 1.2, 4.9). The average treatment costs were $1,640 and $895 for DH and OP programs, respectively. In the midlevel psychiatric severity group, the cost of obtaining an additional person abstinent from alcohol in the DH cohort was approximately $5,464. Among the 405 self-selected subjects, DH was related to abstinence (OR = 2.1; 95% CI = 1.3, 3.5). CONCLUSIONS Although significant benefits of the DH program were not found in the randomized study, DH treatment was associated with better outcomes in the self-selected group. However, for subjects with mid-level psychiatric severity in both the randomized and self-selected samples, the DH program produced higher rates of abstention and was more cost-effective. Self-selection in studies that randomize patients to services requiring very different levels of commitment may be important in interpreting findings for clinical practice.
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Affiliation(s)
- C Weisner
- Kaiser Division of Research, Oakland, CA 94611, USA
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Weisner C, McLellan AT, Hunkeler EM. Addiction severity index data from general membership and treatment samples of HMO members. One case of norming the ASI. J Subst Abuse Treat 2000; 19:103-9. [PMID: 10963921 DOI: 10.1016/s0740-5472(99)00103-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Addiction Severity Index (ASI) is a widely used interview among substance-dependent populations in treatment. Its value as a treatment planning and evaluation tool has been diminished by the lack of comparative data from nonclinical samples. The present study included four scales from the ASI collected on samples of adult subscribers to a large health maintenance organization (HMO) in northern California, as well as an adult clinical sample from the same geographic region with the same HMO insurance, thereby offering informative contrasts. Interviews (N = 9,398) of non-alcohol-dependent or abuse adults from a random sample of members of a large HMO were analyzed. We collected complete ASI data on the alcohol, drug, medical, and psychiatric composite scales and partial data on the employment scale. A sample of 327 adult members of the same HMO from one of the counties included in the survey, who were admitted to treatment for alcohol and/or drug addiction, was administered the same ASI items at treatment admission. Analyses compare problem severities in the two samples by age and gender. The general membership reported some problems in most of the ASI problem areas, although at levels of severity that were typically far below those seen in the clinical sample. General membership and clinical samples were somewhat similar in medical status and in employment. As expected, alcohol, drug, and psychiatric status were much more severe in the clinical sample. The data from the HMO general membership sample provide one potential comparison group against which to judge the severity of problems presented by drug- and alcohol-dependent patients at treatment admission and at posttreatment follow-up. The authors discuss the implications for treatment planning and the evaluation of treatment outcome.
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Affiliation(s)
- C Weisner
- Department of Psychiatry, University of California, 401 Parnassus, Box 0984, 94143, San Francisco, CA, USA
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Hunkeler EM, Meresman JF, Hargreaves WA, Fireman B, Berman WH, Kirsch AJ, Groebe J, Hurt SW, Braden P, Getzell M, Feigenbaum PA, Peng T, Salzer M. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000; 9:700-8. [PMID: 10927707 DOI: 10.1001/archfami.9.8.700] [Citation(s) in RCA: 312] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Primary care treatment of depression needs improvement. OBJECTIVE To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING Two managed care adult primary care clinics. PARTICIPANTS A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.
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Affiliation(s)
- E M Hunkeler
- Division of Research, Kaiser Permanente Northern California, Oakland 94611-5463, USA.
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Abstract
The objective of this study was to examine the association of medical care use (outpatient visits and hospitalization) with alcohol drinking patterns in a large health maintenance organization (HMO). Data were gathered from a random sample of 10,292 adult respondents through a telephone survey conducted between June 1994 and February 1996. Findings indicate that current nondrinkers with no past history of drinking had higher rates of outpatient visits and hospitalizations than current drinkers. Among current drinkers, medical care use declined slightly as drinking levels increased. Among nondrinkers, those with a drinking history exhibited significantly higher use of outpatient visits and hospital care than nondrinkers with no drinking history and current drinkers. Controlling for demographic and socioeconomic factors, health status, and common medical conditions in multivariate analyses suggests that nondrinkers with a drinking history use more services because they are sicker than other nondrinkers or current drinkers.
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Affiliation(s)
- D P Rice
- Institute for Health & Aging, University of California, San Francisco 94118, USA.
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Weisner C, Conell C, Hunkeler EM, Rice D, McLellan AT, Hu TW, Fireman B, Moore C. Drinking patterns and problems of the "stably insured": a study of the membership of a health maintenance organization. J Stud Alcohol 2000; 61:121-9. [PMID: 10627105 DOI: 10.15288/jsa.2000.61.121] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This article describes drinking patterns and examines the prevalence of heavy drinking and alcohol problems, and their association with other behavioral and social problems within the membership of a health maintenance organization, a setting in which increasing numbers of Americans receive services. METHOD The sample is representative of the stably insured membership of the Northern California Region of Kaiser Permanente Medical Care Program; i.e., those who have been insured continuously under that plan for 30 months or longer. A telephone survey of the adult membership (N = 10,292) was conducted between June 1994 and February 1996. RESULTS As in other studies, health and mental health status and smoking were related to drinking levels, with symptoms higher for those in the heaviest drinking group. However, in contrast to studies of those using medical services, demographic characteristics (e.g., young age) were not associated with heavy drinking in this population. When controlling for drug use and drinking, however, women and those reporting any mental health symptom were more likely to report alcohol problems. CONCLUSIONS Findings suggest that in private managed care populations, particular behavioral indicators may be more important than demographic characteristics in screening for problem drinkers. The identification of individuals who report a mental health symptom, who drink a large number of drinks occasionally or who report any drug use may be important in a health maintenance approach to prevention and case finding.
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Affiliation(s)
- C Weisner
- Department of Psychiatry, University of California, San Francisco 94143-0984, USA
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Walter LJ, Schaefer C, Albright L, Parthasarathy S, Hunkeler EM, Westphal J, Williams M. Role of a psychiatric outcome study in a large scale quality improvement project. Eval Program Plann 1999; 22:233-243. [PMID: 24011416 DOI: 10.1016/s0149-7189(99)00001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A psychiatric outcomes study that examined caseload attributes, patterns of treatment, and clinical outcomes in 950 adult outpatients was conducted as part of a Quality Improvement (QI) initiative in a large HMO. Patients were assessed pre- and post-treatment with measures of symptomatology (SCL-90) and functioning (SF-36), plus pre-treatment measures of personality disorder, comorbid problems, and sociodemographic variables. Significant improvements in psychological functioning and symptomatology were seen for 39-50% of patients, while 4-11% had significantly worsened. The study not only provided the HMO with useful baseline information on the performance of its psychiatric services, but also provided important lessons in how to conduct outcomes projects relevant to QI efforts. The study should be seen as part of an early effort of a large organization to move from a paradigm of Quality Assurance to one of Quality Improvement in the area of mental health.
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Affiliation(s)
- L J Walter
- The Permanente Medical Group, Division of Research, 3505 Broadway Avenue, Oakland, CA 94611, USA
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Hu T, Hunkeler EM, Weisner C, Li E, Grayson DK, Westphal J, McLellan AT. Treatment participation and outcome among problem drinkers in a managed care alcohol outpatient treatment program. J Ment Health Adm 1997; 24:23-34. [PMID: 9033153 DOI: 10.1007/bf02790477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
This article uses Markov analysis to investigate patterns of treatment participation of 361 patients treated in the alcohol and drug abuse programs of a large group model Health Maintenance Organization (HMO) to examine how participation is related to abstinence. Findings indicate that 82% of the patients in treatment one month after intake were in treatment three months later, and treatment retention dropped to 46% by month 6. Findings also indicate that 74% of patients abstinent and in treatment at month 1 remained so at month 3. Abstinence at the first three-month interval was a strong predictor of abstinence at later time periods. A multivariate analysis showed that an expressed desire to stop alcohol use upon entry into treatment was the most consistent predictor of both treatment participation and abstinence at most time points. Treatment participation was also a significant predictor of abstinence.
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Affiliation(s)
- T Hu
- Kaiser Permanente Medical Care Program, Division of Research, Oakland, CA 94611, USA
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Hunkeler EM, Westphal J, Williams M. Computer assisted patient evaluation systems: advice from the trenches. Behav Healthc Tomorrow 1996; 5:73-5. [PMID: 10158046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- E M Hunkeler
- Kaiser Permanente Medical Care Program, Oakland, CA 94611, USA
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Hunkeler EM, Westphal JR, Williams M. Developing a system for automated monitoring of psychiatric outpatients: a first step to improve quality. HMO Pract 1995; 9:162-7. [PMID: 10170167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To evaluate an automated system of quality monitoring for psychiatric outpatients. DESIGN Cross-sectional study. SETTING Large outpatient psychiatry clinic in Kaiser Permanente--Northern California. PARTICIPANTS Approximately 1500 new psychiatric patients and 20 clinicians. INTERVENTIONS This system gave clinicians data on new patients from validated instruments before their intake interviews, measured outcomes for the depressed and panic-disordered patients, and monitored the clinic's case-mix. MAIN OUTCOME MEASURES Clinic case-mix: Axis II disorders (Personality Disorder Questionnaire--Revised); emotional, social and physical functioning (Health Status Questionnaire 2.0); Axis I symptoms (Symptom Checklist-90); depression and panic disorder (Health Outcomes Institute Modules). Clinician reaction to system (telephone interview). RESULTS The study population was 62.4% female; 73.9% Caucasian; 70% employed; 15.9% had evidence of personality disorder; 63% reduced daily activities because of emotional problems; 18% had depression; 7% had panic disorder. Over 75% of clinicians used the data reports and found them helpful; criticism focused on questionnaire length, inadequate training, numerous false-positives, and insufficient administrative support. CONCLUSION An automated patient monitoring system can be implemented; clinician involvement needs to be significant; more research is needed to establish the usefulness of standardized data and outcomes management.
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Affiliation(s)
- E M Hunkeler
- Division of Research, Kaiser Permanente Medical Care Program, Northern California, Oakland, USA
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Berman WH, Darling H, Hurt SW, Hunkeler EM. Culture shock and synergy. Academic/managed care/corporate alliances in outcomes management. Behav Healthc Tomorrow 1994; 3:23-9. [PMID: 10141017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The Behavioral Health Outcomes Study is a partnership in conducting outcomes measurement involving a corporate healthcare purchaser, five managed behavioral healthcare organizations and academic researchers. The goals of this study are to: evaluate the feasibility of incorporating patient self-reported data in outcomes research; identify factors that may be predictors of outcome; and evaluate the effectiveness of an employee-sponsored aftercare program. The differing perspectives and needs of the three partners have created a number of challenges in the areas of goals, confidentiality, proprietary vs. open access issues and methodology. However, after the study's first year, it is clear not only that outcomes research can be conducted under such a partnership, but that the partnership generates a kind of synergy in problem-solving.
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Affiliation(s)
- W H Berman
- Department of Psychology, Fordham University, Bronx, NY 10458
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Soghikian K, Casper SM, Fireman BH, Hunkeler EM, Hurley LB, Tekawa IS, Vogt TM. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Med Care 1992; 30:855-65. [PMID: 1518317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BP) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patient's BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8, 1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was $88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI: $16.11, $54.74). The annualized cost of implementing the home BP system was approximately $28 per patient during the study year and would currently be approximately $15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.
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Affiliation(s)
- K Soghikian
- Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA 94611-5463
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Abstract
Three methodologic issues (definitions of smoking, period of follow-up, composition of study group) were assessed in 426 persons five years after participation in a stop smoking program of a prepaid medical plan. When smoking was defined by measurement interval or by type or amount of tobacco smoked, smoking rates varied only slightly. Little information was gained by extending the follow-up period beyond the first year. However, study group composition (as defined by attendance at program sessions) had a pronounced effect on smoking rates. Those who attended fewer sessions were more likely to smoke during the follow-up period.
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Abstract
The rate of occurrence of stones of the urinary tract was assessed in a large population served by the Northern California Kaiser Foundation Health Plan. The study involved three separate groups. First, data were obtained by questionnaire from approximately 175,000 adults who took a multiphasic health checkup in the period 1964-1972; of these generally well adult members, 26.2/1000 persons (32.0/1000 men and 21.0/1000 women) reported having ever been told by a physician that they had a urinary tract stone. Second, data were obtained from 139,000 persons served by the San Francisco outpatient facility in 1970-1972; 1.22/1000 per year (1.81/1000 men and 0.59/1000 women) had an initial diagnosis of a "new or recurrent" stone of the upper urinary tract. The third set of data was procured from the entire Northern California region in 1971-1975; 0.36/1000 (0.52/1000 men and 0.19/1000 women) were discharged from a hospital each year with a diagnosis of upper urinary tract stone. All rates were age-adjusted to the 1960 US Census population. Of these three rates, the rate derived from the outpatient visit record most closely estimates incidence, since nearly all persons who are hospitalized are first seen as outpatients. Rates of kidney stone diagnosis were three times more common in men and, although rare before 20 years of age, the frequency increased rapidly and peaked in the age group 40 to 59 years. Rates were approximately twice as high in whites as in blacks and Orientals; the frequency of stones was inversely related to socioeconomic status as measured by level of education. Over 90% of stones occurred in the upper urinary tract, and the majority contained calcium oxalate. Population-based rates of occurrence of kidney stones are not generally available in the United States. Comparisons with the few available studies indicate that rates in the Kaiser Foundation Health Plan population may be high.
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