Quality

PI: Richard C. Hermann, M.D., Harvard University
Grant No.: R01 HS10303
Grant Period: 9/30/99-9/29/01
Title: Quality Measures for Severe/Persistent Mental Illness

Description: The aim of this research was to: (1) identify, inventory, and describe existing measures of the quality of mental health care for individuals with severe and persistent mental illness; (2) develop selected measures and test their meaningfulness and feasibility; and (3) implement selected measures as part of ongoing efforts to improve the quality of treatment provided to patients with severe and persistent mental illness. The study focused specifically on Medicaid and Department of Mental Health patients in Massachusetts.

Findings: These researchers used a case study of one organization's experience to demonstrate the implementation of a quality management program in a behavioral health care delivery system. The case study emphasized how theoretical frameworks were operationalized and how organizational structure and process were shaped to address challenges well known in quality management, such as authority, accountability, and follow-through. The study revealed that continuous quality improvement (CQI) activities had some impact in some areas. For example, by changing off-unit privileges for patients undergoing detoxification, CQI reduced high readmission rates for patients who were admitted for both a mental disorder and active substance abuse and who had previously left the program. Adolescent inpatient services used interventions such as staff training in de-escalation techniques to reduce the high rates of physical restraint of adolescents.

Quality of care measures are particularly underdeveloped in the area of mental health. This research project analyzed 86 process measures that were developed to assess the quality of mental health care. Most measures evaluate treatment of major mental disorders, such as schizophrenia and major depression, with a few focusing on children or the elderly. Domains of quality include treatment appropriateness, care continuity, access, coordination of care, disease detection, and disease prevention.

PI: Laura A. Nabors, Ph.D., University of Maryland, Baltimore
Grant No.: R03 HS09542
Grant Period: 9/30/97-9/29/99
Title: School Mental Health—Quality Assessment and Improvement

Description: The objective of this pilot program study was to assess the impact of quality assurance activities and evaluation outcomes related to therapy services. School-based mental health therapy services were provided by therapists working through the Center for School Mental Health Assistance to 150 students aged 13-19 years at three high schools in Baltimore City, with 80 percent of the students from minority populations. Stakeholder focus groups (consisting of students, parents, therapists, health center staff, health department personnel, teachers, and school administrators) and student and parent interviews were conducted to inform the quality assurance and program evaluation components of the study.

Findings: This study successfully developed a systematic approach to evaluating school mental health programs. This step-by-step process was published in the August 2000 Community Mental Health Journal 36(4):395-411. Another aspect of this study found that the costs of the evaluated program were relatively low when compared to other programs, such as those in the community or the private sector. These findings are described in the May 2000 Journal of School Health 70(5):206-9.

PI: Laura A. Nabors, Ph.D., University of Maryland, Baltimore
Grant No.: R03 HS09847
Grant Period: 9/1/99-8/31/01
Title: School Mental Health: Quality Care and Positive Outcome

Description: The purpose of this study was to examine the relationship between treatment process and youth outcomes in school mental health programs by (1) testing and refining current measures for assessing youth outcomes (including satisfaction and resilience); (2) conducting focus groups with clinicians to refine clinician and youth-report instruments; and (3) tracking youth outcomes and quality over time. The researchers studied 320 youths from low-income families aged 11-18 years and attending one of four Baltimore City middle and high schools.

Findings: Successfully conducting evaluations of school mental health programs depends on the evaluators overcoming several challenges that relate to the internal and external validity of their results.

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Schizophrenia

PI: Patricia P. Dickersin, Ph.D., University of Maryland (Small Conference Grant)
Grant No.: R13 HS09818
Grant Period: 5/1/98-2/28/99
Title: Cochrane VI-Systematic Reviews: Evidence for Action

Description: This grant funded an annual meeting of the Cochrane Collaboration, an international nonprofit organization that prepares, maintains, and promotes the accessibility of evidence-based health care information. Members of the Collaborative Review Groups performed reviews addressing health care interventions concerning numerous diseases, including schizophrenia, and the conference proposed to build on such information. Dissemination of the reviews was done primarily through the Cochrane Database of Systematic Reviews.

Findings: Conference proceedings are available for a fee from the National Technical Information Service, 800-553-NTIS. The NTIS accession no. is PB2000- 101193. The Cochrane Collaboration posts its reviews on its Web site: www.cochrane.org.

PI: Anthony F. Lehman, M.D., University of Maryland
Contract Number: 290-92-0054
Contract Period: 9/30/92-7/31/00
Title: Schizophrenia Patient Outcomes Research Team (PORT)

Description: The purpose of this study was to assess practice variations in the treatment and management of schizophrenia and analyze them for relative patient outcomes, resource use, and remaining scientific uncertainties. Recommendations for treatment and management were developed and disseminated to practitioners and the public. This project also evaluated the effectiveness of the dissemination effort in terms of measurable patient outcomes, practice patterns, public awareness and attitudes, and resource use.

Findings: This project completed a major literature review that summarized the key findings in all areas of treatment for schizophrenia (pharmacotherapies, psychological and family interventions, vocational rehabilitation, and assertive community treatment).

The most important product developed through the PORT is evidence-based treatment recommendations that also focus on the therapies identified above. These recommendations are a synthesis of the best scientific evidence from well-controlled research. The level of evidence for each recommendation is also included, and both the strengths and limitations in our current knowledge base are identified.

Patterns of care were also studied through the PORT. Findings show that less than half of schizophrenic patients are receiving proper doses of antipsychotic medications or appropriate psychosocial interventions. Other findings include: younger patients were more likely to be offered psychotherapy and vocational rehabilitation; minority patients were more likely to be on higher doses of antipsychotic medications and less often prescribed an antidepressant when depressed; psychosocial treatments are often prescribed at the point of hospital discharge but follow-through in the community is low and failure to offer these treatments for outpatients may be a serious problem in ongoing community-based care; and psychosocial treatment varied in conformance rates based on location, with patients in some States more likely than those in another to be prescribed a vocational intervention and less likely to be prescribed a family intervention or psychotherapy.

The researchers also found that only one-fourth of schizophrenics with Medicare coverage received any outpatient care in 1991. Being black, male, 65 or older, or having a substance abuse diagnosis was associated with a lower likelihood of receiving any outpatient services. Among people under 65 years of age, whites were about 1.5 times as likely as blacks to have received outpatient care and 1.3 times as likely to have received individual therapy.

Researchers also analyzed the association of race with past and current diagnoses and with current treatment for depression, mania, and anxiety disorders. White patients with schizophrenia were significantly more likely than black patients to report lifetime diagnosis (56 vs. 41 percent), current diagnosis (37 vs. 32 percent), and current treatment (34 vs. 30 percent) for depression. White patients also were more likely than black patients to report lifetime diagnosis, current diagnosis, and current treatment of manic-depressive disorder or anxiety disorder, despite similar self-reported symptoms of these mood disorders. Since blacks in this study reported more psychotic symptoms (for example, hallucinations and delusions) than whites, differences in symptom presentation may have caused doctors to more frequently confuse manic-depression with schizophrenia among blacks. This confusion also may be related to the use of white patients' presentation of symptoms as the basis for most research and diagnostic tools on mood disorders. Nevertheless, standard care includes assertive treatment of both affective and psychotic symptoms, whether they are coexisting problems or components of the same disorder. Black patients were less likely than white patients in this study to receive such assertive care.

Veterans with schizophrenia who received treatment through the Department of Veterans Affairs (VA) were less likely to have access to state-of-the-art community-based services than non-VA patients. During the time frame being evaluated (1994-96), the VA relied mostly on hospital-based rather than community-based services, but since then, the VA has expanded outpatient care services to include more recovery-oriented care.

PI: Bradley C. Martin, Ph.D., University of Georgia Research Foundation, Inc.
Grant No.: R03 HS10815
Grant Period: 7/1/00-1/31/02
Title: Advancing Risk Adjustment for Schizophrenia

Description: The purpose of this study was to develop and validate a prospective risk-adjustment index with predictive capability for schizophrenia. The index used administrative data and was based on selected previous approaches to construct such an index. The index was expected to provide greater predictive ability than constituent indices.

Findings: No findings are available at this time.

PI: Linda E. Rose, Ph.D., Johns Hopkins University
Grant No.: R03 HS10378
Grant Period: 9/30/99-9/29/01
Title: Implementing Family Programs in Psychiatric Settings

Description: This research aimed to investigate the factors influencing the availability of access to interventions and services for families when a family member either is hospitalized with an acute episode of schizophrenia or bipolar disorder or is receiving long-term care in a community-based treatment setting. The study conducted various focus groups, consisting of health care providers, families, patients, and mental health advocates, in the Baltimore area. Barriers to family interventions were identified and suggestions for improvement to family programs were proposed.

Findings: This study provides evidence that implementation of guidelines for family care is a complex undertaking that needs to take into account the constraints of the current health system as well as the wishes of the families. Many of the problems and concerns raised by families have been documented in previous studies, and the evidence on which the recommendations for family care are based is substantial and convincing. It was also noted that fewer than 50 percent of families are receiving such care. Health professionals identified two major barriers to the provision of care: (1) lack of system-based resources and support, and (2) lack of clear and explicit practice guidelines that incorporate responsibility and accountability for such care. The following conclusions and recommendations are offered from the findings of this study:

1. Health professionals do not see extensive (e.g., 9-month) interventions with families as feasible in the current health care system. Alternative approaches to family care need to be investigated.
2. Families want support from health professionals that consists of thoughtful, respectful interactions that are not rushed.
3. African-American families have specific concerns related to their own community's response to mental illness that need to be addressed.
4. There is a lack of coordination of services for both patients and families from inpatient care to community-based care. As a result, patients and families do not always get the care they need.
5. Adolescents have specific needs that were suggested in this study and warrant further study.
6. Health professionals are dealing with a wide variety of family situations and do not always know how to proceed. Ongoing education for staff is essential if families are to be engaged in care.
7. Standardized interventions are helpful for delivering basic education to families about mental illness, but often the educational materials available to staff are outdated or not comprehensive. Such standardized approaches need to be supplemented with individualized instruction and support based on a family's need and the patient's stage of illness.
8. Community-based support groups such as the National Alliance for the Mentally Ill (NAMI) provide vital services to families. Their contributions need to be recognized and supported by the health care system. Family participants who were not a part of the NAMI group had not been told about NAMI and were not aware of it.
9. Patients were aware of the importance of their relationships with family members. They also wanted the family to be better educated about their illness.
10. A major point of intervention for families is helping them understand the health care system and how to make it work for them. Getting a patient into the hospital, and dealing with police and emergency rooms are major sources of stress. Future studies need to investigate the experiences of families in crisis and the roles of emergency personnel in that experience.
11. The issue of patient confidentiality is of great concern to families, who see it as a major barrier to working with health professionals. This issue and its ramifications need to be explored in future studies.

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Stress

PI: Timothy Carey, M.D., University of North Carolina
Grant No.: T32 HS00032
Grant Period: 9/1/89-6/30/03
Title: University of North Carolina, Chapel Hill, Training Program in Health Services Research

Description: The predoctoral program invites applications from advanced doctoral candidates in any of 10 academic departments of the School of Public Health (Health Policy and Administration; Epidemiology; Biostatistics; Health Behavior and Health Education; and Maternal and Child Health) or the Division of Academic Affairs (Economics; Sociology; Political Science; Geography; and Anthropology). On completion of the training program, both predoctoral and postdoctoral trainees will have gained a generalized background in contemporary health policy issues and the historical significance of these issues, a solid understanding of the most common statistical and study design methods applicable to health services research and policy analysis, and experience in the design and conduct of health services research under the supervision of at least one mentor with expertise in the subject and methods being used. They will also receive a set of materials to use as supporting references in their own work and a set of publishable data.

Findings: Traditionally, doctors have had almost complete control over their practices. However, as third parties (managed care plans, traditional insurers, and employers) exert more influence on the practice of medicine, physician job control dissipates, exposing doctors to ever-increasing stress. This project tests a model relating job stress to four intentions to withdraw from practice mediated by job satisfaction and perceptions of physical and mental health. The model suggests that higher perceived stress is associated with lower physician satisfaction levels, which in turn are related to greater intention to quit, decrease work hours, change specialty, or leave direct patient care. Doctors experiencing burnout, anxiety, and depression seem to deal with these problems by leaving patient care in some way other than quitting their jobs, decreasing work hours, or changing specialty. Higher levels of perceived stress result in poorer perceptions of physical health, which link with greater intentions to change specialty.

Also analyzed as part of this post-doctoral program was the prevalence of stressful life events and physical abuse among women prior to delivery. Women who are abused before and during pregnancy also show a high level of stressful life events, identified as residential moves, increased arguments with husbands/partners, family member hospitalizations, financial hardship, and deaths of loved ones. Because of the high frequency of these events and the abuse, a woman's care provider should ask patients about their lives and make referrals where appropriate.

PI: Allison C. Jeffrey, Virginia Polytechnic Institute and State University (Dissertation Grant)
Grant No.: R03 HS10036
Grant Period: 9/30/98-5/31/99
Title: Secondary Trauma Feedback to Domestic Violence Workers

Description: The purpose of this dissertation was to study the incidence of secondary traumatic stress (STS) among domestic violence workers, specifically assessing the base rate for STS, the success of protection with coping skills, and the effectiveness of advice to alleviate STS.

Findings: This dissertation is not available at this time.

PI: Lisa S. Meredith, Ph.D., RAND (Dissertation Grant)
Grant No.: R03 HS06622
Grant Period: 9/1/90-8/31/91
Title: Effects of Stressful Life Events on Health Outcomes

Description: The objective of this study was to investigate how stressful life events affect health outcomes of chronically ill elderly men and women over time and to develop a model for scoring life events across age groups. This research used data from the Medical Outcomes Study regarding 2,400 patients with one of four chronic illnesses (hypertension, diabetes, advanced coronary artery disease, and depression).

Findings: On the whole, except for resignation, retirement, and bereavement, the frequency of stressful events and of negative stressful events decrease with increasing age. Overall stress (health events excluded) seems to be associated with a few measures of health, such as increased symptomatology. Chronic as compared with acute events of a negative nature were associated with lowered levels of social functioning and increased fatigue; acute events were associated with increased pain. On the whole, older chronically ill people appear to adapt relatively well to stress as compared with younger ones.

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Tools

PI: Paul D. Cleary, Ph.D., Harvard University (Cooperative Agreement)
Grant No.: U18 HS09205
Grant Period: 9/30/95-9/29/01
Title: Consumer Assessment of Health Plans Study

Description: The goals of the project were to: (1) produce survey protocols for collecting reliable and valid information from consumers regarding their assessments of health plans and services, (2) develop and test the effectiveness of different report formats for conveying results to consumers and benefits managers, (3) demonstrate the resulting survey protocols, and (4) evaluate the usefulness of the survey information for consumers and purchasers selecting health plans and services. The study team selected the survey developed by the Research Triangle Institute under contract to AHRQ as the foundation for the proposed project. Special attention was devoted to refining the modules for, among others, persons with mental health problems.

Findings: The consumer survey, Consumer Assessment of Behavioral Health care Services (CABHS), can identify which aspects of the health insurance plan and treatment are priorities for improvement. Adult patients from both commercial health plans and public assistance plans were surveyed. Both commercial and public assistance respondents were least satisfied with the promptness of treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services. The Experience of Care and Health Outcomes survey (ECHO™) was developed specifically to assess consumers' ratings of their behavioral health treatment, including mental health, alcohol and drug, and other substance abuse services. Managed behavioral health care organization and health plan versions of ECHO™ are currently available. ECHO™ will soon be incorporated into the Consumer Assessment of Health Plans (CAHPS®). Copies of the ECHO™ survey and additional information regarding ECHO™ are available at www.hcp.med.harvard.edu/echo/home.html.

PI: Donald Goldman, M.D., Children's Hospital, Boston
Grant No.: T32 HS00063
Grant Period: 9/30/94-6/30/03
Title: Health Services Research for Children and Families

Description: This grant to the Division of General Pediatrics and the Department of Hospital Epidemiology and Quality Improvement funds a training program that is preparing two fellows each year with the skills necessary for carrying out health services research focusing on services affecting children and families. Trainees obtain core methodologic training in the disciplines of clinical epidemiology, biostatistics, health policy and services research, and quality improvement through an established program for physicians at the Harvard School of Public Health. Supplementary pediatric health services methods are taught in seminars at Children's Hospital.

Findings: A growing number of troubled children and adolescents are showing up at hospital emergency departments (EDs), primarily for self-destructive behavior. By asking them just four questions, non-mental-health professionals in the ED can quickly identify children and adolescents who are suicidal, a critical first step to getting them into treatment. Responses to the four questions asked by the triage nurse identified 98 percent of children at risk for suicide, based on a standard 30-item Suicide Ideation Questionnaire (SIQ) later administered to them by a mental health clinician. The four questions assessed major factors in suicide risk: present and past thoughts of suicide, prior self-destructive behavior, and current stressors. Adding 10 questions to these 4 on the Risk of Suicide Questionnaire (RSQ) did not significantly improve the accuracy of identifying suicidal patients. The RSQ took less than 2 minutes to complete, and ED nurses reported in a post-study focus group that it reduced the stress of handling such patients. In addition, patients felt it was acceptable to discuss suicidal thoughts they had kept to themselves. For the most part, parents were relieved that a clinician was delving into a topic that they feared discussing with their children.

PI: David H. Gustafson, Ph.D., University of Wisconsin
Grant No.: R18 HS06177
Grant Period: 7/1/90-6/30/93
Title: Impact of Computer Support on HIV Infected

Description: This study aimed to assess the impact of the Comprehensive Health Enhancement Support System (CHESS) on the health services utilization, health status, and risk behaviors of HIV-positive patients as compared to those patients without access to CHESS. The study made CHESS available to males presenting to HIV testing sites in Milwaukee and Madison for a 3-week period in their homes and then in community sites. The study also analyzed cost and use patterns.

Findings: CHESS was formally tested and validated as a useful tool for influencing health services utilization, health status, and risk behaviors of HIV-positive patients. CHESS was later adapted, under funding by the National Cancer Institute, to aid smokers in trying to quit. A CHESS adaptation for cognitive behavior therapy was initially developed as part of the smoking cessation module. CHESS has also been, and will continue to be, generalized to adapt to other areas.

PI: David H. Gustafson, Ph.D., University of Wisconsin (Small Conference Grant)
Grant No.: R03 HS09567
Grant Period: 9/30/97-9/29/98
Title: Computer System to Support Alzheimer's Decisionmaking

Description: The objective of this pilot project was to develop a new decisionmaking component for the Alzheimer's module of the Comprehensive Health Enhancement Support System (CHESS) and adapt a new behavior change program so that CHESS would support the implementation of decisions related to Alzheimer's disease by family caregivers. The project funded enhancements to the existing Alzheimer's CHESS program to best accommodate the individual needs of the different populations accessing CHESS. The decision support components were pilot tested to obtain a preliminary sense of its acceptance, use, and potential effects on the quality of life of family caregivers and their relationship with providers.

Findings: The outcomes of this research are currently being built upon by a research project funded by the California Foundation in which the researchers are developing and testing the Alzheimer's module in California. The Alzheimer's module is also being tested in the CHESS Research Consortium, a group of nine health care providers, including health plans, hospitals, and major medical centers.

PI: David A. Katerndahl, M.D., University of Texas Health Science Center, San Antonio
Grant No.: R03 HS10676
Grant Period: 4/1/00-3/31/01
Title: Stability of Psychiatric Symptoms in Primary Care

Description: The purpose of this pilot study was to determine the best methods to test the Dynamic Model of Mental Health Problems, a model used to represent the ever-changing levels of anxiety, depression, and physical symptoms that occur in patients, as opposed to the rather static criteria of the diagnostic system for mental disorders (DSM) currently used in health care settings. Mostly female, mostly Hispanic, primary care patients were randomly assigned to one of three groups—self-report interview, face-to-face interview, and telephone interview—and were surveyed at baseline and monthly for up to 6 months to assess their levels of anxiety, depression, and somatization.

Findings: The results of the study offer support for the Dynamic Model, with 47 percent of the subjects crossing the nondistressed-distressed threshold at least one time. The structured versus self-answer interview methods yielded similar results. The telephone and face-to-face followup methods yielded similar followup rates. However, the face-to-face interviews produced data that were more sensitive to social desirability.

PI: John V. Lavigne, Ph.D., Children's Memorial Hospital, Chicago
Grant No.: R01 MH59462 (co-funded with National Institute of Mental Health)
Grant Period: 9/1/98-5/31/02
Title: Treating Oppositional Defiant Disorder in Primary Care

Description: This study examined the effectiveness of using a psychological intervention in primary care pediatric settings to help identify and treat preschool children with oppositional defiant disorder (ODD). It also evaluated how well a 10-week training program on parenting skills reduced the incidence of ODD and how well the intervention reduced the use of ambulatory and emergency room care. Two primary care treatment models for children aged 4-6 years with ODD, including a parent-training intervention with manually driven treatment and videotapes, were administered by either a pediatric nurse or mental health care professional and compared to a control group of families provided with usual care.

Findings: No findings are available at this time.

PI: Roderick K. Mahurin, Ph.D., Battelle Memorial Institute, Seattle (Small Meeting Grant)
Grant No.: R03 HS09828
Grant Period: 9/30/98-9/29/99
Title: Expert System Diagnosis of Depression and Dementia

Description: The purpose of this study was to design and validate an expert decision system and a neural network classification system. The systems would be able to diagnose and differentiate between depression and dementia in the elderly. The systems were to be developed through four phases: knowledge acquisition, prototype development, usability testing, and system validation.

Findings: No findings are available at this time.

PI: Ian W. Mcdowell, M.D., M.Sc., University of Ottawa
Grant No.: R01 HS06206
Grant Period: 9/1/89-12/31/91
Title: Measuring Health, Revised Edition

Description: The purpose of this grant was to fund the preparation of a second, expanded edition of a reference book entitled Measuring Health: A Guide to Rating Scales and Questionnaires. Chapter topics already included physical disability, psychological well being, social health, pain measurement, quality of life, and general health measurements. This reference book provides a critical overview of the field of health measurement by giving full descriptions and copies of over 80 health measurement methods, summarizing the reliability and validity of each, and providing the information readers need to select the most appropriate measurement for their purposes and then apply and score the method chosen. The second edition includes a chapter on anxiety and depression, among other topics, as well as updates on the previous edition.

Findings: Measuring Health: A Guide to Rating Scales and Questionnaires, Second Edition, was published July 18, 1996, by Oxford University Press and contains chapters covering health status measurement scales for both depression and mental status testing. Ordering information is available at www.oup.co.uk/isbn/0-19-510371-8.

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