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Leung LB, Zhang E, Chu K, Yoo C, Gabrielian S, Der-Martirosian C. Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset. J Gen Intern Med 2024; 39:53-59. [PMID: 38252239 PMCID: PMC10937850 DOI: 10.1007/s11606-023-08462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/21/2023] [Accepted: 10/06/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness. OBJECTIVE To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic. DESIGN Retrospective cohort study, 3/16/2019-3/15/2022. PARTICIPANTS 394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits. MAIN MEASURES The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing). KEY RESULTS Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42-0.44), women (OR = 1.74, CI: 1.70-1.78), Black (OR = 1.14, CI: 1.12-1.16), Hispanic (OR = 1.34, CI: 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services. CONCLUSIONS Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Division of General Internal Medicine, UCLA David Geffen School of Medicine/Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Eunice Zhang
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Caroline Yoo
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Sonya Gabrielian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Veterans Affairs Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Claudia Der-Martirosian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
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Leung LB, Chrystal JG, Dyer KE, Brayton CE, Karakashian MA, Yano EM, Young AS, Shekelle PG, Hamilton AB. Primary care provider perspectives on virtual and in-person depression management during the COVID-19 pandemic. Fam Syst Health 2023; 41:443-453. [PMID: 37227826 PMCID: PMC10674027 DOI: 10.1037/fsh0000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, primary care providers (PCPs), nurses, and integrated mental health specialists continued to collaboratively manage depression among patients using both in-person and virtual (i.e., hybrid) modalities. Few studies have characterized how hybrid services are currently delivered within interdisciplinary primary care teams. This study aimed to understand frontline PCPs' perspectives on providing hybrid virtual and in-person depression care during the pandemic. METHOD From September to November 2020, 12 semistructured individual interviews focused on depression management were conducted with PCPs in two Veterans Health Administration (VA) clinics in Los Angeles, which resumed in-person services while balancing rising COVID-19 cases. Interviews were audio-recorded, transcribed, and coded for depression management patterns. Themes were derived using a team-based constant comparative analytic approach. RESULTS The pandemic and subsequent expanded use of virtual care necessitated clinic adaptations to depression assessments and procedures. PCPs perceived increased depression and anxiety among patients with existing psychiatric conditions, attributed to social distancing and isolation restrictions. They expressed acceptance of virtual care modalities for patients' depression management. PCPs did not perceive a delay in mental health care delivery in the shift to virtual care but noted the possibility of patients being lost to follow-up. CONCLUSIONS During the pandemic, there has been heightened PCP concern for patients' emotional well-being and adaptations of clinic processes to meet needs for depression care. While PCPs were optimistic about new virtual care options for depression management, virtual care transfers remained poorly defined and the extent to which patient care experiences and health outcomes have been disrupted remains unknown. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Joya G Chrystal
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Karen E Dyer
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Catherine E Brayton
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Michael A Karakashian
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Alexander S Young
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Paul G Shekelle
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
| | - Alison B Hamilton
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System
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O’Hanlon CE, Walling AM, McClean M, Chu K, Lindvall C, Lee M, Stockdale SE, Leung LB. Depression care quality among patients with solid tumor cancers detected to have depression in Veterans Health Administration primary care clinics. Psychol Serv 2023; 20:764-769. [PMID: 37616079 PMCID: PMC10843783 DOI: 10.1037/ser0000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/25/2023]
Abstract
Patients with cancer, especially advanced cancer, experience depression at high rates. We aimed to evaluate the quality of depression care received by patients with solid tumor cancer and advanced solid tumor cancer in Veterans Affairs (VA) primary care clinics. This is a retrospective cohort study of patients seen in 82 VA primary care clinics who newly screened positive for depression on the Patient Health Questionnaire (PHQ-2). Outcomes included timely follow-up within 84 or 180 days (3+ mental health specialty, 3+ psychotherapy, or 3+ primary care visits with depression diagnosis codes) and minimum treatment within 1 year (60+ days antidepressants prescribed, 4+ mental health specialty visits, or 3+ psychotherapy visits). 608,042 individuals were seen in VA primary care clinics during this period; 49,839 patients (8.2%) had solid tumor cancer and 9,278 (1.5%) had advanced or poor-prognosis solid tumor cancer. For 686 observations of patients with cancer and new depression, rates of appropriate follow-up were 22.3% within 84 days and 38.2% within 180 days. For 73 observations of patients with advanced or poor-prognosis cancer and new depression, rates of appropriate follow-up were 21.9% within 84 days and 34.3% within 180 days. Rates of minimum treatment within 1 year were 68.4% and 64.4% for patients with cancer and patients with advanced or poor-prognosis cancer, respectively. Quality of timely depression management is low in patients with solid tumor cancers. Even in health systems with well-integrated mental health services, care gaps remain for patients with cancer and depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Claire E. O’Hanlon
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy
| | - Anne M. Walling
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy, UCLA Department of General Internal Medicine and Health Services Research
| | - Michael McClean
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy
| | - Karen Chu
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy
| | - Charlotta Lindvall
- Dana-Farber Cancer Institute Department of Psychosocial Oncology and Palliative Care (POPC), Brigham and Women’s Hospital Department of Medicine
| | - Martin Lee
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy
| | - Susan E. Stockdale
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy
| | - Lucinda B. Leung
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy, UCLA Department of General Internal Medicine and Health Services Research
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Leung LB, Yoo CK, Rose DE, Jackson NJ, Stockdale SE, Apaydin EA. Telework Arrangements and Physician Burnout in the Veterans Health Administration. JAMA Netw Open 2023; 6:e2340144. [PMID: 37889491 PMCID: PMC10611990 DOI: 10.1001/jamanetworkopen.2023.40144] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/16/2023] [Indexed: 10/28/2023] Open
Abstract
This survey study of physicians in the Veterans Health Administration examines the association of burnout with various telework arrangements.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
| | - Caroline K. Yoo
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Danielle E. Rose
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Nicholas J. Jackson
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Susan E. Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
| | - Eric A. Apaydin
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- RAND Corporation, Santa Monica, California
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Rose DE, Leung LB, McClean M, Nelson KM, Curtis I, Yano EM, Rubenstein LV, Stockdale SE. Associations Between Primary Care Providers and Staff-Reported Access Management Challenges and Patient Perceptions of Access. J Gen Intern Med 2023; 38:2870-2878. [PMID: 37532877 PMCID: PMC10593665 DOI: 10.1007/s11606-023-08172-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/20/2022] [Accepted: 03/13/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND/OBJECTIVE Optimizing patients' access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. METHODS Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans' perceived access from 2018-2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). MAIN MEASURES The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. ANALYTIC APPROACH We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. KEY RESULTS Veterans at clinics with more access management challenges (> 75th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR: .86, 95% CI: .78-.95); always receiving routine appointments (AOR: .74, 95% CI: .67-.82); and always reporting same- or next-day answers to telephone questions (AOR: .79, 95% CI: .70-.90) compared to veterans receiving care at clinics with fewer (< 25th percentile) challenges. DISCUSSION/CONCLUSION Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience.
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Affiliation(s)
- Danielle E Rose
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Lucinda B Leung
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michael McClean
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karin M Nelson
- VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Elizabeth M Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Fielding School of Public Health, UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Susan E Stockdale
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
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Puac-Polanco V, Ziobrowski HN, Ross EL, Liu H, Turner B, Cui R, Leung LB, Bossarte RM, Bryant C, Joormann J, Nierenberg AA, Oslin DW, Pigeon WR, Post EP, Zainal NH, Zaslavsky AM, Zubizarreta JR, Luedtke A, Kennedy CJ, Cipriani A, Furukawa TA, Kessler RC. Development of a model to predict antidepressant treatment response for depression among Veterans. Psychol Med 2023; 53:5001-5011. [PMID: 37650342 PMCID: PMC10519376 DOI: 10.1017/s0033291722001982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/06/2022]
Abstract
BACKGROUND Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA). METHODS A 2018-2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample. RESULTS In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors. CONCLUSIONS Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.
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Affiliation(s)
| | | | - Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Brett Turner
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ruifeng Cui
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Robert M. Bossarte
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Corey Bryant
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
| | - Jutta Joormann
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Andrew A. Nierenberg
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - David W. Oslin
- VISN 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilfred R. Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nur Hani Zainal
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Statistics, Harvard University, Cambridge, MA, USA
- Department of Biostatistics, Harvard University, Cambridge, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Chris J. Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Toshiaki A. Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Ziobrowski HN, Cui R, Ross EL, Liu H, Puac-Polanco V, Turner B, Leung LB, Bossarte RM, Bryant C, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Nierenberg AA, Luedtke A, Kennedy CJ, Kessler RC. Development of a model to predict psychotherapy response for depression among Veterans. Psychol Med 2023; 53:3591-3600. [PMID: 35144713 PMCID: PMC9365879 DOI: 10.1017/s0033291722000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/07/2022]
Abstract
BACKGROUND Fewer than half of patients with major depressive disorder (MDD) respond to psychotherapy. Pre-emptively informing patients of their likelihood of responding could be useful as part of a patient-centered treatment decision-support plan. METHODS This prospective observational study examined a national sample of 807 patients beginning psychotherapy for MDD at the Veterans Health Administration. Patients completed a self-report survey at baseline and 3-months follow-up (data collected 2018-2020). We developed a machine learning (ML) model to predict psychotherapy response at 3 months using baseline survey, administrative, and geospatial variables in a 70% training sample. Model performance was then evaluated in the 30% test sample. RESULTS 32.0% of patients responded to treatment after 3 months. The best ML model had an AUC (SE) of 0.652 (0.038) in the test sample. Among the one-third of patients ranked by the model as most likely to respond, 50.0% in the test sample responded to psychotherapy. In comparison, among the remaining two-thirds of patients, <25% responded to psychotherapy. The model selected 43 predictors, of which nearly all were self-report variables. CONCLUSIONS Patients with MDD could pre-emptively be informed of their likelihood of responding to psychotherapy using a prediction tool based on self-report data. This tool could meaningfully help patients and providers in shared decision-making, although parallel information about the likelihood of responding to alternative treatments would be needed to inform decision-making across multiple treatments.
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Affiliation(s)
| | - Ruifeng Cui
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | | | - Brett Turner
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Robert M. Bossarte
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Corey Bryant
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
| | - Wilfred R. Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - David W. Oslin
- VISN 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Statistics, Harvard University, Cambridge, MA, USA
- Department of Biostatistics, Harvard University, Cambridge, MA, USA
| | - Andrew A. Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Chris J. Kennedy
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Bossarte RM, Ross EL, Liu H, Turner B, Bryant C, Zainal NH, Puac-Polanco V, Ziobrowski HN, Cui R, Cipriani A, Furukawa TA, Leung LB, Joormann J, Nierenberg AA, Oslin DW, Pigeon WR, Post EP, Zaslavsky AM, Zubizarreta JR, Luedtke A, Kennedy CJ, Kessler RC. Development of a model to predict combined antidepressant medication and psychotherapy treatment response for depression among veterans. J Affect Disord 2023; 326:111-119. [PMID: 36709831 PMCID: PMC9975041 DOI: 10.1016/j.jad.2023.01.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/07/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although research shows that more depressed patients respond to combined antidepressants (ADM) and psychotherapy than either alone, many patients do not respond even to combined treatment. A reliable prediction model for this could help treatment decision-making. We attempted to create such a model using machine learning methods among patients in the US Veterans Health Administration (VHA). METHODS A 2018-2020 national sample of VHA patients beginning combined depression treatment completed self-report assessments at baseline and 3 months (n = 658). A learning model was developed using baseline self-report, administrative, and geospatial data to predict 3-month treatment response defined by reductions in the Quick Inventory of Depression Symptomatology Self-Report and/or in the Sheehan Disability Scale. The model was developed in a 70 % training sample and tested in the remaining 30 % test sample. RESULTS 30.0 % of patients responded to treatment. The prediction model had a test sample AUC-ROC of 0.657. A strong gradient was found in probability of treatment response from 52.7 % in the highest predicted quintile to 14.4 % in the lowest predicted quintile. The most important predictors were episode characteristics (symptoms, comorbidities, history), personality/psychological resilience, recent stressors, and treatment characteristics. LIMITATIONS Restrictions in sample definition, a low recruitment rate, and reliance on patient self-report rather than clinician assessments to determine treatment response limited the generalizability of results. CONCLUSIONS A machine learning model could help depressed patients and providers predict likely response to combined ADM-psychotherapy. Parallel information about potential harms and costs of alternative treatments would be needed, though, to inform optimal treatment selection.
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Affiliation(s)
- Robert M Bossarte
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA; Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Eric L Ross
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Howard Liu
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Brett Turner
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Corey Bryant
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
| | - Nur Hani Zainal
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Victor Puac-Polanco
- Department of Health Policy and Management, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Hannah N Ziobrowski
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Ruifeng Cui
- VISN 4 Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Toshiaki A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jutta Joormann
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - David W Oslin
- VISN 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Edward P Post
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA; Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; Department of Statistics, Harvard University, Cambridge, MA, USA; Department of Biostatistics, Harvard University, Cambridge, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Chris J Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
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9
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Leung LB, Yoo C, Chu K, O’Shea A, Jackson NJ, Heyworth L, Der-Martirosian C. Rates of Primary Care and Integrated Mental Health Telemedicine Visits Between Rural and Urban Veterans Affairs Beneficiaries Before and After the Onset of the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e231864. [PMID: 36881410 PMCID: PMC9993180 DOI: 10.1001/jamanetworkopen.2023.1864] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 03/08/2023] Open
Abstract
IMPORTANCE Telemedicine can increase access to care, but uptake has been low among people living in rural areas. The Veterans Health Administration initially encouraged telemedicine uptake in rural areas, but telemedicine expansion efforts have broadened since the COVID-19 pandemic. OBJECTIVE To examine changes over time in rural-urban differences in telemedicine use for primary care and for mental health integration services among Veterans Affairs (VA) beneficiaries. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined 63.5 million primary care and 3.6 million mental health integration visits across 138 VA health care systems nationally from March 16, 2019, to December 15, 2021. Statistical analysis took place from December 2021 to January 2023. EXPOSURES Health care systems with most clinic locations designated as rural. MAIN OUTCOMES AND MEASURES For every system, monthly visit counts for primary care and mental health integration specialties were aggregated from 12 months before to 21 months after pandemic onset. Visits were categorized as in person or telemedicine, including video. A difference-in-difference approach was used to examine associations in visit modality by health care system rurality and pandemic onset. Regression models also adjusted for health care system size as well as relevant patient characteristics (eg, demographic characteristics, comorbidities, broadband internet access, and tablet access). RESULTS The study included 63 541 577 primary care visits (6 313 349 unique patients) and 3 621 653 mental health integration visits (972 578 unique patients) (6 329 124 unique patients among the cohort; mean [SD] age, 61.4 [17.1] years; 5 730 747 men [90.5%]; 1 091 241 non-Hispanic Black patients [17.2%]; and 4 198 777 non-Hispanic White patients [66.3%]). In fully adjusted models for primary care services before the pandemic, rural VA health care systems had higher proportions of telemedicine use than urban ones (34% [95% CI, 30%-38%] vs 29% [95% CI, 27%-32%]) but lower proportions of telemedicine use than urban health care systems after pandemic onset (55% [95% CI, 50%-59%] vs 60% [95% CI, 58%-62%]), signifying a 36% reduction in the odds of telemedicine use (odds ratio [OR], 0.64; 95% CI, 0.54-0.76). The rural-urban telemedicine gap was even larger for mental health integration (OR, 0.49; 95% CI, 0.35-0.67) than for primary care services. Few video visits occurred across rural and urban health care systems (unadjusted percentages: before the pandemic, 2% vs 1%; after the pandemic, 4% vs 8%). Nonetheless, there were rural-urban divides for video visits in both primary care (OR, 0.28; 95% CI, 0.19-0.40) and mental health integration services (OR, 0.34; 95% CI, 0.21-0.56). CONCLUSIONS AND RELEVANCE This study suggests that, despite initial telemedicine gains at rural VA health care sites, the pandemic was associated with an increase in the rural-urban telemedicine divide across the VA health care system. To ensure equitable access to care, the VA health care system's coordinated telemedicine response may benefit from addressing rural disparities in structural capacity (eg, internet bandwidth) and from tailoring technology to encourage adoption among rural users.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine–Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles
| | - Caroline Yoo
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, California
| | - Amy O’Shea
- Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Nicholas J. Jackson
- Division of General Internal Medicine–Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles
| | - Leonie Heyworth
- Office of Connected Care/Telehealth Services, Veterans Health Administration, Washington, DC
- Department of Medicine, University of California San Diego School of Medicine, San Diego
| | - Claudia Der-Martirosian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, California
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10
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Leung LB, Ziobrowski HN, Puac-Polanco V, Bossarte RM, Bryant C, Keusch J, Liu H, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Kessler RC. Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration. J Gen Intern Med 2022; 37:3235-3241. [PMID: 34613577 PMCID: PMC8493943 DOI: 10.1007/s11606-021-07136-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes. OBJECTIVE To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment. DESIGN Patient self-report surveys at treatment initiation linked to medical records. SETTING Veterans Health Administration (VA) clinics nationally, 2018-2020. PARTICIPANTS A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables. KEY RESULTS More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence. CONCLUSIONS Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Division of General Internal Medicine, and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | | | - Victor Puac-Polanco
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Robert M Bossarte
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA.,Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA
| | - Corey Bryant
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Janelle Keusch
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - David W Oslin
- Cpl Michael J Crescenz VA Medical Center, VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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11
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Leung LB, Rubenstein LV, Jaske E, Taylor L, Post EP, Nelson KM, Rosland AM. Association of Integrated Mental Health Services with Physical Health Quality Among VA Primary Care Patients. J Gen Intern Med 2022; 37:3331-3337. [PMID: 35141854 PMCID: PMC9550947 DOI: 10.1007/s11606-021-07287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 06/28/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Integrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management. OBJECTIVE To examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016. MAIN MEASURE(S) For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA's established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics. KEY RESULTS Median proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7-8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96-0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92-0.99; p=0.046) lower adjusted odds of having elevated blood pressures. CONCLUSIONS AND RELEVANCE Primary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd (111G), Los Angeles, CA, 90073, USA. .,Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, WA, USA
| | | | - Edward P Post
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karin M Nelson
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington Medical School, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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12
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Leung LB, Chu K, Rose D, Stockdale S, Post EP, Wells KB, Rubenstein LV. Electronic Population-Based Depression Detection and Management Through Universal Screening in the Veterans Health Administration. JAMA Netw Open 2022; 5:e221875. [PMID: 35267029 PMCID: PMC8914576 DOI: 10.1001/jamanetworkopen.2022.1875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/14/2022] Open
Abstract
IMPORTANCE In 2016, the US Preventive Services Task Force newly recommended universal screening for depression, with the expectation that screening would be associated with appropriate treatment. Few studies have been able to assess the population-based trajectory from screening to receipt of follow-up and treatment for individuals with depression. OBJECTIVE To examine adherence to guidelines for follow-up and treatment among primary care patients who newly screened positive for depression in the Veterans Health Administration (VA). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used VA electronic data to identify patients who newly screened positive for depression on the 2-item Patient Health Questionnaire at 82 primary care VA clinics in California, Arizona, and New Mexico between October 1, 2015, and September 30, 2019. Data analysis was performed from December 2020 to August 2021. MAIN OUTCOMES AND MEASURES Receipt of guideline-concordant care for screen-positive patients who were determined by clinicians as having depression was assessed. Timely follow-up (within 84 days of screening) was defined as receiving 3 or more mental health specialty visits, 3 or more psychotherapy visits, or 3 or more primary care visits with a depression diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Completing at least minimal treatment (within 12 months) was defined as having 60 days or more of antidepressant prescriptions filled, 4 or more mental health specialty visits, or 3 or more psychotherapy visits. RESULTS The final cohort included 607 730 veterans (mean [SD] age, 59.4 [18.2] years; 546 516 men [89.9%]; 339 811 non-Hispanic White [55.9%]); 8%, or 82 998 of 997 185 person-years, newly screened positive for depression. Clinicians identified fewer than half with depression (15 155 patients), of whom 32% (5034 of 15 650 person-years) met treatment guidelines for timely follow-up and 77% (12 026 of 15 650 person-years) completed at least minimal treatment. Younger age (odds ratio, 0.990; 95% CI, 0.986-0.993; P < .001), Black race (odds ratio, 1.19; 95% CI, CI 1.05-1.34; P = .01), and having comorbid psychiatric diagnoses were significantly associated with timely follow-up. Individual quality metric components (eg, medication or psychotherapy) were associated differently with overall quality results among patient groups, except for age. CONCLUSIONS AND RELEVANCE In this cohort study, most patients met the guidelines for completing at least minimal treatment, but only a minority received timely follow-up after screening positive and being identified as having depression. More research is needed to understand whether the discrepancy between patients who screened positive and patients identified as having depression reflects a gap in recognition of needed care.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Edward P. Post
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Kenneth B. Wells
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California
- RAND Corporation, Santa Monica, California
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13
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Leung LB, Rose D, Guo R, Brayton CE, Rubenstein LV, Stockdale S. Mental health care integration and primary care patient experience in the Veterans Health Administration. Healthc (Amst) 2021; 9:100587. [PMID: 34601395 PMCID: PMC11014737 DOI: 10.1016/j.hjdsi.2021.100587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care. OBJECTIVES To examine the relationship between primary care patient experience and mental health integration. RESEARCH DESIGN Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics. MEASURES Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists. RESULTS 50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01). CONCLUSIONS No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Catherine E Brayton
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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14
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Leung LB, Benitez CT, Dorsey C, Mahajan AP, Hellemann GS, Whelan F, Park NJ, Braslow JT. Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System. Med Care 2021; 59:975-979. [PMID: 34432766 PMCID: PMC9012483 DOI: 10.1097/mlr.0000000000001637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/25/2022]
Abstract
BACKGROUND Beginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications. OBJECTIVE The aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation. METHODS This retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics. RESULTS 9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety, <1% alcohol, and substance use disorders). Odds of visits being associated with psychiatric diagnoses were 9% higher [95% confidence interval (CI)=1.05-1.13; P<0.0001], and 10% higher for diagnoses that were new (CI=1.04-1.16; P=0.002), after MHIP implementation than before. This appeared to be fueled by increased visits for depression post-MHIP (odds ratio=1.11; CI=1.06-1.15; P<0.0001). CONCLUSIONS MHIP implementation was associated with more psychiatric diagnoses coded in safety-net primary care visits. Scaling up this effort will require greater attention to the notable differences across patient populations and languages, as well as the markedly low coding of alcohol and substance use services in primary care.
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Affiliation(s)
- Lucinda B. Leung
- VA Greater Los Angeles Healthcare System, HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, Los Angeles, CA
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
| | | | - Charmaine Dorsey
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Anish P. Mahajan
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Gerhard S. Hellemann
- UCLA Semel Institute for Neuroscience and Human Behavior, Biostatistics Core, Los Angeles, CA
| | - Fiona Whelan
- UCLA Semel Institute for Neuroscience and Human Behavior, Biostatistics Core, Los Angeles, CA
| | - Nina J. Park
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Joel T. Braslow
- UCLA Semel Institute for Neuroscience and Human Behavior, Center for Social Science and Humanities, Los Angeles, CA
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15
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Ziobrowski HN, Leung LB, Bossarte RM, Bryant C, Keusch JN, Liu H, Puac-Polanco V, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Kessler RC. Comorbid mental disorders, depression symptom severity, and role impairment among Veterans initiating depression treatment through the Veterans Health Administration. J Affect Disord 2021; 290:227-236. [PMID: 34004405 PMCID: PMC8508583 DOI: 10.1016/j.jad.2021.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 12/15/2020] [Revised: 01/21/2021] [Accepted: 04/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Psychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates. METHODS 2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments. RESULTS Nearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities. LIMITATIONS The screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities. CONCLUSIONS Although positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.
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Affiliation(s)
| | - Lucinda B. Leung
- Center for the Study of Healthcare Innovation,
Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles,
CA, USA,Division of General Internal Medicine and Health Services
Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Robert M. Bossarte
- Department of Behavioral Medicine and Psychiatry, West
Virginia University, Morgantown, WV, USA,Center of Excellence for Suicide Prevention, Canandaigua VA
Medical Center, Canandaigua, NY, USA
| | - Corey Bryant
- Center for Clinical Management Research, VA Ann Arbor, Ann
Arbor, MI, USA
| | - Janelle N. Keusch
- Center for Clinical Management Research, VA Ann Arbor, Ann
Arbor, MI, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA,Center of Excellence for Suicide Prevention, Canandaigua VA
Medical Center, Canandaigua, NY, USA
| | - Victor Puac-Polanco
- Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA,Department of Epidemiology, Columbia University Mailman
School of Public Health, New York, NY, USA
| | - Wilfred R. Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA
Medical Center, Canandaigua, NY, USA,Department of Psychiatry, University of Rochester Medical
Center, Rochester, NY, USA
| | - David W. Oslin
- VISN 4 Mental Illness Research Education and Clinical
Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor, Ann
Arbor, MI, USA,Department of Medicine, University of Michigan Medical
School, Ann Arbor, MI, USA
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA,Department of Statistics, Harvard University, Cambridge,
MA, USA
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA,Department of Statistics, Harvard University, Cambridge,
MA, USA,Department of Biostatistics, Harvard University,
Cambridge, MA, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School,
Boston, MA, USA
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16
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Essien UR, Tipirneni R, Leung LB, Sterling MR. Surviving and Thriving as Leaders in General Internal Medicine-Reply. J Gen Intern Med 2021; 36:1435-1436. [PMID: 33464463 PMCID: PMC8131485 DOI: 10.1007/s11606-020-06363-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Renuka Tipirneni
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Madeline R Sterling
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
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17
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Leung LB, Rose D, Rubenstein LV, Guo R, Dresselhaus TR, Stockdale S. Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey. J Gen Intern Med 2020; 35:3620-3626. [PMID: 32948952 PMCID: PMC7728981 DOI: 10.1007/s11606-020-06203-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 03/24/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Burnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being. OBJECTIVE To examine the relationships between PCP-reported burnout (and secondarily, job satisfaction) and mental health integration at provider and clinic levels DESIGN: Analysis of 286 cross-sectional surveys in 2012 (n = 171) and 2013 (n = 115) PARTICIPANTS: 210 PCPs in one VA region MAIN MEASURES: Outcomes were PCP-reported burnout (Maslach Burnout Inventory emotional exhaustion subscale), and secondarily, job satisfaction. Two independent variables represented mental health integration: (1) PCP-specialty communication rating and (2) proportion of clinic patients who saw integrated specialists. Using multilevel regression models, we examined PCP-reported burnout (and job satisfaction) and mental health integration, adjusting for PCP characteristics (e.g., gender), PCP ratings of team functioning (communication, knowledge/skills, satisfaction), and organizational factors. KEY RESULTS On average, PCPs reported high burnout (29, range = 9-54) across all VA healthcare systems. In total, 46% of PCPs reported "very easy" communication with mental health; 9% of primary clinic patients had seen integrated specialists. Burnout was not significantly associated with mental health communication ratings (β coefficient = - 0.96, standard error [SE] = 1.29, p = 0.46), nor with proportion of clinic patients who saw integrated specialists (β = 0.02, SE = 0.11, p = 0.88). No associations were observed with job satisfaction either. Among study participants, PCPs with poor team functioning, as exhibited by low team communication ratings, reported high burnout (β = - 1.28, SE = 0.22, p < 0.001) and low job satisfaction (β = 0.12, SE = 0.02, p < 0.001). CONCLUSIONS As currently implemented, primary care and mental health integration did not appear to impact PCP-reported burnout, nor job satisfaction. More research is needed to explore care model variation among clinics in order to optimize implementation to enhance PCP well-being.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA.,Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Timothy R Dresselhaus
- Primary Care Service, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Medicine, UCSD School of Medicine, San Diego, CA, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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18
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Essien UR, Tipirneni R, Leung LB, Sterling MR. Surviving and Thriving as Physicians in General Internal Medicine Fellowship in the Twenty-First Century. J Gen Intern Med 2020; 35:3664-3670. [PMID: 32342480 PMCID: PMC7728835 DOI: 10.1007/s11606-020-05837-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/12/2019] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
General internal medicine (GIM) fellowships play an important role in the development of physician scientists and clinical educators, as well as leaders in academic medicine. Nevertheless, the challenges of developing another novel aspect to one's career, along with balancing coursework, research productivity, clinical duties, and personal life during fellowship, can be overwhelming. Similarly, successfully securing a job at the end of fellowship can be a daunting process. In this article, we discuss the foundational tenets and themes of the GIM fellowship. These themes include (1) finding your purpose and passion, with a focus on selecting research coursework and developing an area of study; (2) the role and importance of mentorship, including the various kinds of mentorship that fellows require (traditional and peer mentorship, sponsors, and coaches), as well as how to be an effective mentee; (3) securing research funding; (4) landing a job; (5) and protecting time to meet personal goals. There is an increased need for a vibrant, diverse, and successful generation of general internal medicine researchers to advance our understanding of complex issues in clinical medicine and healthcare delivery and to inform health policy. It is our hope that this piece helps to support that mission.
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Affiliation(s)
- Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Renuka Tipirneni
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Madeline R Sterling
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
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19
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Leung LB, Young AS, Heyworth L, Rose D, Stockdale S, Graaff AL, Dresselhaus TR, Rubenstein LV. Do Collaborative Care Managers and Technology Enhance Primary Care Satisfaction with Care from Embedded Mental Health Providers? J Gen Intern Med 2020; 35:3458-3464. [PMID: 32556874 PMCID: PMC7728939 DOI: 10.1007/s11606-020-05660-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 03/04/2019] [Revised: 08/06/2019] [Accepted: 12/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND To improve mental health care access, the Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) in clinics nationally. Primary care clinical leader satisfaction can inform model implementation and may be facilitated by collaborative care managers and technology supporting cross-specialty collaboration. OBJECTIVE (1) To determine primary care clinical leaders' overall satisfaction with care from embedded mental health providers for a range of conditions and (2) to examine the association between overall satisfaction and two program features (care managers, technology). DESIGN Cross-sectional organizational survey in one VA region (Southern California, Arizona, and New Mexico), 2018. PARTICIPANTS Sixty-nine physicians or other designated clinical leaders in each VA primary care clinic (94% response rate). MAIN MEASURES We assessed primary care clinical leader satisfaction with embedded mental health care on four groups of conditions: target, non-target mental health, behavioral health, suicide risk management. They additionally responded about the availability of mental health care managers and the sufficiency of information technology (telemental health, e-consult, instant messaging). We examined relationships between satisfaction and the two program features using χ2 tests and multivariable regressions. KEY RESULTS Most primary care clinical leaders were "very satisfied" with care for targeted anxiety (71%) and depression (69%), but not for other common conditions (37% alcohol misuse, 19% pain). Care manager availability was significantly associated with "very satisfied" responses for depression (p = .02) and anxiety care by embedded mental health providers (p = .02). Highly rated sufficiency of communication technology (only 19%) was associated with "very satisfied" responses to suicide risk management (p = .002). CONCLUSIONS Care from embedded mental health providers for depression and anxiety was highly satisfactory, which may guide improvement among less satisfactory conditions (alcohol misuse, pain). Observed associations between overall satisfaction and collaborative care features may inform clinics on how to optimize staffing and technology based on priority conditions.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Alexander S Young
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Leonie Heyworth
- Office of Connected Care/Telehealth, Department of Veterans Affairs Central Office, Washington, DC, USA.,Department of Medicine, UCSD School of Medicine, San Diego, CA, USA
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - A Laurie Graaff
- VISN 22 (VA Desert Pacific Healthcare Network) Primary Care Coordinator, Gilbert, AZ, USA
| | - Timothy R Dresselhaus
- Department of Medicine, UCSD School of Medicine, San Diego, CA, USA.,Primary Care Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA.,Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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20
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Leung LB, Steers WN, Hoggatt KJ, Washington DL. Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation. PLoS One 2020; 15:e0240306. [PMID: 33044984 PMCID: PMC7549758 DOI: 10.1371/journal.pone.0240306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022] Open
Abstract
Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.
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Affiliation(s)
- Lucinda B. Leung
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Katherine J. Hoggatt
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
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21
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Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Netw Open 2020; 3:e2020955. [PMID: 33079197 PMCID: PMC7576407 DOI: 10.1001/jamanetworkopen.2020.20955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 11/16/2022] Open
Abstract
IMPORTANCE Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Ranak B. Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Menlo Park, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Jean Yoon
- VA Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California, San Francisco
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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22
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Leung LB, Dyer KE, Yano EM, Young AS, Rubenstein LV, Hamilton AB. Collaborative care clinician perceptions of computerized cognitive behavioral therapy for depression in primary care. Transl Behav Med 2020; 10:565-572. [PMID: 32766864 DOI: 10.1093/tbm/ibz122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/12/2022] Open
Abstract
In Veterans Health Administration's (VA) Primary Care-Mental Health Integration (PC-MHI) models, primary care providers, care managers, and mental health clinicians collaboratively provide depression care. Primary care patients, however, still lack timely, sufficient access to psychotherapy treatment. Adapting PC-MHI collaborative care to improve uptake of evidence-based computerized cognitive behavioral therapy (cCBT) may be a potential solution. Understanding primary care-based mental health clinician perspectives is crucial for facilitating adoption of cCBT as part of collaborative depression care. We examined PC-MHI mental health clinicians' perspectives on adapting collaborative care models to support cCBT for VA primary care patients. We conducted 16 semi-structured interviews with PC-MHI nurse care managers, licensed social workers, psychologists, and psychiatrists in one VA health-care system. Interviews were audio-recorded, transcribed, coded using the constant comparative method, and analyzed for overarching themes. Although cCBT awareness and knowledge were not widespread, participants were highly accepting of enhancing PC-MHI models with cCBT for depression treatment. Participants supported cCBT delivery by a PC-MHI care manager or clinician and saw it as an additional tool to engage patients, particularly younger Veterans, in mental health treatment. They commented that current VA PC-MHI models did not facilitate, and had barriers to, use of online and mobile treatments. If effectively implemented, however, respondents thought it had potential to increase the number of patients they could treat. There is widespread interest in modernizing health systems. VA PC-MHI mental health clinicians appear open to adapting collaborative care to increase uptake of cCBT to improve psychotherapy access.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Karen E Dyer
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Alexander S Young
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Alison B Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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23
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Yoon J, Leung LB, Rubenstein LV, Nelson K, Rose DE, Chow A, Stockdale SE. Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care. Healthc (Amst) 2020; 8:100429. [PMID: 32553525 DOI: 10.1016/j.hjdsi.2020.100429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/23/2020] [Accepted: 04/22/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care. METHODS A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains. RESULTS Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition. CONCLUSIONS Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care. IMPLICATIONS Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Jean Yoon
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA; Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
| | - Lucinda B Leung
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation in Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Adam Chow
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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Leung LB, Rubenstein LV, Yoon J, Post EP, Jaske E, Wells KB, Trivedi RB. Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access. Health Aff (Millwood) 2019; 38:1281-1288. [DOI: 10.1377/hlthaff.2019.00270] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lucinda B. Leung
- Lucinda B. Leung is a core investigator in the Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the University of California Los Angeles (UCLA) David Geffen School of Medicine
| | - Lisa V. Rubenstein
- Lisa V. Rubenstein is a professor emerita of medicine in the Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, and the Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Jean Yoon
- Jean Yoon is a health economist at the Health Economics Resource Center, VA Palo Alto Healthcare System, in Menlo Park, California, and the University of California San Francisco
| | - Edward P. Post
- Edward P. Post is the national Primary Care–Mental Health Integration medical director in the Veterans Health Administration based out of the VA Ann Arbor Healthcare System and a professor of medicine in the Division of General Medicine, University of Michigan, in Ann Arbor
| | - Erin Jaske
- Erin Jaske is a data analyst in the Primary Care Analytics Team, VA Puget Sound Healthcare System, in Seattle, Washington
| | - Kenneth B. Wells
- Kenneth B. Wells is the director of the UCLA Center for Health Services and Society; a professor of psychiatry in the Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior; and an associate investigator at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System
| | - Ranak B. Trivedi
- Ranak B. Trivedi is a core investigator at the Center for Innovation to Implementation, VA Palo Alto Healthcare System, and an assistant professor of psychiatry in the Department of Public Mental Health and Population Sciences, Stanford University, in Menlo Park, California
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Abstract
Using survey data on (N = 419) patients at Department of Veterans Affairs (VA) clinics we analyzed women veterans' reports of timely access to VA mental health care. We evaluated problems that patients might face in obtaining care, and examined subjective ratings of VA care as a function of timely access to mental health care. We found that 59% of participants reported "always" getting an appointment for mental health care as soon as needed. In adjusted analyses, two problems were negatively associated with timely access to mental health care: (a) medical appointments that interfere with other activities, and (b) difficulty getting questions answered between visits. Average subjective ratings of VA ranged from 8.2-8.6 out of 10, and 93% of participants would recommend VA care. Subjective ratings of VA were higher among women who reported timely access to mental health care. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patient questions between visits. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Julian Brunner
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System
| | - C Amanda Schweizer
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System
| | - Ismelda A Canelo
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System
| | - Lucinda B Leung
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System
| | - Jennifer L Strauss
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs
| | - Elizabeth M Yano
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System
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Leung LB, Yoon J, Escarce JJ, Post EP, Wells KB, Sugar CA, Yano EM, Rubenstein LV. Primary Care-Mental Health Integration in the VA: Shifting Mental Health Services for Common Mental Illnesses to Primary Care. Psychiatr Serv 2018; 69:403-409. [PMID: 29241440 DOI: 10.1176/appi.ps.201700190] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 11/30/2022]
Abstract
OBJECTIVE Primary care-mental health integration (PC-MHI) aims to increase access to general mental health specialty (MHS) care for primary care patients thereby decreasing referrals to non-primary care-based MHS services. It remains unclear whether new patterns of usage of MHS services reflect good mental health care. This study examined the relationship between primary care clinic engagement in PC-MHI and use of different MHS services. METHODS This was a retrospective longitudinal cohort study of 66,638 primary care patients with mental illnesses in 29 Southern California Veterans Affairs clinics (2008-2013). Regression models used clinic PC-MHI engagement (proportion of all primary care clinic patients who received PC-MHI services) to predict relative rates of general MHS visits and more specialized MHS visits (for example, visits for serious mental illness services), after adjustment for year and clinic fixed effects, other clinic interventions, and patient characteristics. RESULTS Patients were commonly diagnosed as having depression (35%), anxiety (36%), and posttraumatic stress disorder (22%). For every 1 percentage point increase in a clinic's PC-MHI engagement rate, patients at the clinic had 1.2% fewer general MHS visits per year (p<.001) but no difference in more specialized MHS visits. The reduction in MHS visits occurred among patients with depression (-1.1%, p=.01) but not among patients with psychosis; however, the difference between the subsets was not statistically significant. CONCLUSIONS Primary care clinics with greater engagement in PC-MHI showed reduced general MHS use rates, particularly for patients with depression, without accompanying reductions in use of more specialized MHS services.
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Affiliation(s)
- Lucinda B Leung
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Jean Yoon
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - José J Escarce
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Edward P Post
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Kenneth B Wells
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Catherine A Sugar
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Elizabeth M Yano
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
| | - Lisa V Rubenstein
- Dr. Leung, Dr. Yano, and Dr. Rubenstein are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Leung is also with the Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), David Geffen School of Medicine, where Dr. Escarce is affiliated. Dr. Yano and Dr. Escarce are also with the UCLA Fielding School of Public Health, Los Angeles, where Dr. Sugar is affiliated. Dr. Yano and Dr. Escarce are with the Department of Health Policy and Management, and Dr. Sugar is with the Department of Biostatistics. Dr. Rubenstein is also with RAND Corporation, Santa Monica, California. Dr. Sugar is also with the UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, where Dr. Wells is affiliated. Dr. Wells is also with the UCLA Center for Health Services and Society, Los Angeles. Dr. Yoon is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and with the Department of General Internal Medicine, University of California, San Francisco, School of Medicine. Dr. Post is with the VA Center for Clinical Management Research and the University of Michigan Medical School, both in Ann Arbor
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Leung LB, Escarce JJ. Consumer-directed health plans: do doctors and nurses buy in? Am J Manag Care 2017; 23:e89-e94. [PMID: 28385030] [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: 06/07/2023]
Abstract
OBJECTIVES Aiming to increase healthcare value, consumer-directed health plans (CDHPs)-high-deductible health insurance plus a personal spending account-equip enrollees with decision-support tools and expose them to the financial implications of their medical decisions. This study examines whether medically knowledgeable consumers are more or less likely to select a CDHP than individuals without medical knowledge. STUDY DESIGN Using University of California Los Angeles (UCLA) human resources data, our observational cross-sectional study analyzed the health plan enrollment choices of 3552 faculty and 8429 staff employees. METHODS We compared CDHP selection in 2 cohorts: 1) physicians and nonphysician faculty and 2) nurses and nonmedical staff. We used probit regression models to predict CDHP selection, adjusted for job title, demographics (ie, age, gender, race/ethnicity, education, employee income), and coverage type (eg, single). RESULTS Approximately 5% of UCLA employees chose the CDHP. After adjusting for sociodemographic characteristics and coverage type, physicians were less likely to choose these plans than nonmedical faculty, when all other covariates were fixed at their means (predicted probability change [ΔP], -1.6%; standard error [SE], 0.8%; P = .05). Nurses also appeared less inclined to choose these plans than nonmedical staff, which approached statistical significance (ΔP, -1.9%; SE, 1.0%; P = .07). CONCLUSIONS Overall low rates of CDHP selection were observed in consumers with and without medical knowledge. Although physicians and nurses seem to be better positioned as CDHP consumers, they appeared less likely to select these health plans compared with nonmedical faculty and staff in our study.
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Affiliation(s)
- Lucinda B Leung
- UCLA Robert Wood Johnson Foundation VA Clinical Scholars Program, 10940 Wilshire Blvd, Ste 710, Los Angeles, CA 90024. E-mail:
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Leung LB, Vargas-Bustamante A, Martinez AE, Chen X, Rodriguez HP. Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers. Health Serv Res 2016; 53:509-531. [PMID: 27767205 DOI: 10.1111/1475-6773.12590] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 01/04/2023] Open
Abstract
OBJECTIVE To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference. STUDY SETTING/DATA COLLECTION Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053). STUDY DESIGN We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups. PRINCIPAL FINDINGS After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients. CONCLUSIONS Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.
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Affiliation(s)
- Lucinda B Leung
- VA Quality Scholars Program, Greater Los Angeles VA, Los Angeles, CA.,Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles, CA
| | - Arturo Vargas-Bustamante
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Ana E Martinez
- Center for Health Policy Research, UCLA, Los Angeles, CA
| | - Xiao Chen
- Center for Health Policy Research, UCLA, Los Angeles, CA
| | - Hector P Rodriguez
- Division of Health Policy and Management, UC Berkeley School of Public Health, Berkeley, CA
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Leung LB, Simmons JE, Ho J, Anselin E, Yalamanchili R, Rabatin JS. A Five-Year Evolution of a Student-led Elective on Health Disparities at The Alpert Medical School. R I Med J (2013) 2016; 99:43-47. [PMID: 27706279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Medical students are often unprepared for social challenges in caring for safety net patients. We aim to evaluate and chronicle the evolution of a pre-clinical elective alongside medical disparities curriculum. DESIGN AND METHODS Medical students designed the course to supplement clinical training on care of vulnerable patients. From 2011-2015, there have been 80 first-year medical student participants, five cohorts of second-year course leaders, and two supporting faculty advisors for this 10-12 session evening elective. RESULTS Students (n=67) rated the course extremely highly (ranging from 4.4-4.6 on a five-point Likert scale). Medical students reported having significantly more knowledge of underserved populations after taking the course (difference=0.72, SE=0.16, P <0.001). Career interests and attitudes toward health disparities remained strong after taking the course. CONCLUSIONS This student-created elective equipped participants with improved knowledge in caring for underserved patients and contributed to the incorporation of health disparities in medical curriculum. [Full article available at http://rimed.org/rimedicaljournal-2016-10.asp].
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Affiliation(s)
- Lucinda B Leung
- general internist, Robert Wood Johnson Foundation Clinical Scholar / Veteran's Affairs Scholar at University of California Los Angeles, alumnus of Alpert Medical School of Brown University and co-founder of Brown Student Community Clinic and the Healthcare for the Underserved elective
| | - James E Simmons
- pulmonary and critical care fellow at Brown University, alumnus of the Alpert Medical School of Brown University and co-founder of Brown Student Community Clinic and the Healthcare for the Underserved elective
| | - Julius Ho
- medical student at the Alpert Medical School of Brown University and student leader for the Healthcare for the Underserved elective from 2013 to 2014
| | - Emma Anselin
- medical student at the Alpert Medical School of Brown University and student leader for the Healthcare for the Underserved elective from 2013 to 2014
| | - Rian Yalamanchili
- medical student at the Alpert Medical School of Brown University and student leader for the Healthcare for the Underserved elective from 2013 to 2014
| | - Joseph S Rabatin
- Associate Professor of Medicine (Clinical) at the Alpert Medical School of Brown University and faculty sponsor for the Healthcare for the Underserved elective
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Khalili J, Leung LB, Diamant AL. Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians. Am J Public Health 2015; 105:1114-9. [PMID: 25880937 DOI: 10.2105/ajph.2014.302448] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the existence of procedures and policies for identifying lesbian, gay, bisexual, and transgender (LGBT)-competent physicians at US academic faculty practices, and sought to identify physician training programs that enhance LGBT competency. METHODS We invited all 138 Liaison Committee on Medical Education-accredited US academic faculty practices to participate in a survey in 2012. We systematically assessed their procedures and policies to identify LGBT-competent physicians and their LGBT-competency training. We also assessed geographic region, funding source, and an LGBT health center in the same state. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS The response rate was 50%. Few participants had existing procedures (9%) or policies (4%) to identify LGBT-competent physicians. Procedures included online directories with self-identified LGBT-competent physicians available to the public. Sixteen percent of participants reported having comprehensive LGBT-competency training, and 52% reported having no training. Of note, 80% of participants indicated interest to do more to address these issues. CONCLUSIONS There exist both need and interest for US academic faculty practices to develop procedures, policies, and programs that improve access to LGBT-competent physicians and to train physicians to become LGBT-competent.
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Affiliation(s)
- Joshua Khalili
- At the time of the study, Joshua Khalili was a medical student at the David Geffen School of Medicine, University of California, Los Angeles. Lucinda B. Leung was a resident in the Department of Medicine, David Geffen School of Medicine. Allison L. Diamant was with the Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine
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Leung LB, Busch AM, Nottage SL, Arellano N, Glieberman E, Busch NJ, Smith SR. Approach to antihypertensive adherence: a feasibility study on the use of student health coaches for uninsured hypertensive adults. Behav Med 2012; 38:19-27. [PMID: 22356599 PMCID: PMC3311508 DOI: 10.1080/08964289.2011.651174] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [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: 10/28/2022]
Abstract
Despite pharmacologic advances, medication non-adherence continues to challenge primary care providers in blood pressure (BP) management. Medical, nursing and pharmacy students (n=11) were recruited and trained as health coaches for uninsured, hypertensive patients (n=25) of a free clinic in an uncontrolled open trial. Pre-post analysis was conducted on BP, medication adherence, frequency of home BP monitoring, and health behavior (eg, diet, exercise). Patient satisfaction and feasibility of a student coach model was qualitatively evaluated. In the 12 patients who completed the intervention, an increase in medication adherence as measured by the Brief Medication Questionnaire was observed (P<.01), with a 11 mmHg reduction in systolic BP (P=.03). Qualitative data showed patient satisfaction with the intervention and other health behavior change. This feasibility study shows use of student health coaches to combat medication non-adherence in uninsured, hypertensive adults is promising.
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Affiliation(s)
- Lucinda B. Leung
- The Warren Alpert Medical School of Brown University,Rhode Island Free Clinic
| | - Andrew M. Busch
- The Warren Alpert Medical School of Brown University,Rhode Island Free Clinic,The Miriam Hospital
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