Other

PI: Ronald M. Epstein, M.D., University of Rochester
Grant No.: R01 HS10610
Grant Period: 9/30/00-8/31/03
Title: Patient-Centered Care and Health Care Costs

Description: The objective of this study is to examine the relationship between patient-centeredness and health care costs, as well as impact on patient health status and patient satisfaction. The researchers are analyzing data from 100 primary care physicians and 50 patients per physician, administering various questionnaires and reviewing audiotapes to gauge the level of patient-centeredness, and utilizing a managed care database to assess case-mix-adjusted costs. The multimethod research methodology will provide a link between cost data and patient encounters, which may help to improve on, among other things, psychological assessments and detection of mental illness.

Findings: No findings are available at this time.

PI: Michael L. Ganz, B.A., M.S., Ph.D., Harvard School of Public Health
Grant No.: R03 HS13047
Grant Period: 4/1/02-9/30/03
Title: Child Mental Health and Mental Health Service Use

Description: The purpose of this project is to examine the family, socioeconomic, clinical, and insurance correlates of mental health conditions and related services for children in the United States and to provide a baseline for tracking changes in the system over time. This project is motivated by the fact that there is little information about mental-health-related service use for children and about how key factors, including insurance characteristics, influence the use of those services, especially information based on current national surveys. It is also motivated by the fact that changes in financing methods for health insurance coverage for children may have important implications for access and utilization of needed services for children with mental health conditions. Furthermore, little is known about how child mental health conditions and mental health services use impact the family. The specific aims of this project are to: (1) characterize the population of children (21 years of age and under) in the United States who have mental health conditions with respect to family, socioeconomic, clinical, and insurance coverage factors; (2) estimate utilization and expenditure patterns and sources of payment for overall health care and care within specific categories of services by age, diagnosis, insurance coverage groups, and family characteristics; and (3) assess the impact of a child's mental health condition on maternal employment.

Findings: No findings are available at this time.

PI: Michael S. Hendryx, Ph.D., Washington State University (Small Conference Grant)
Grant No.: R13 HS09851
Grant Period: 7/1/99-6/30/00
Title: Public Mental Health Outcomes Risk Adjustment

Description: The purpose of this conference was to implement and assess a research agenda regarding risk-adjustment outcomes and utilization in public mental health organizations. Conference attendees included various public mental health representatives. Presentations focused on previous research on mental health risk adjustment, on important mental health treatments and utilization of health outcomes and predictors, and on current monitoring systems for mental health outcomes. Work group sessions focused on developing a research agenda. In addition to producing a research agenda, the conference intended to generate a structure for implementation of the research agenda and published proceedings.

Findings: The conference generated a written conference report and grant writing plans and teams. Several articles were published in a special section on risk adjustment of the Journal for Mental Health Services Research, Vol. 28, No. 3, August 2001. The meeting summary report is available for a fee from the National Technical Information Service, 800-553-NTIS.

PI: Michael S. Hendryx, Ph.D., Washington State University (Small Conference Grant)
Grant No.: R13 HS10112
Grant Period: 9/15/00-9/14/01
Title: Measuring Mental Health Outcomes Fairly

Description: This conference built on the conference held in 1999 by bringing together various university researchers and public and private mental health representatives to work on developing and implementing a research agenda on valid measurement and use of mental health outcomes. The meeting was a working conference, seeking the long-term objective of implementing and evaluating a valid approach to data collection, risk-adjustment analysis, and reporting in mental health organizations, so that outcomes may be used fairly in comparative evaluation of mental health services organizations. Another aim of the conference was to motivate collaboration projects. Products include a conference proceedings manuscript distributed on the national mental health outcomes E-mail listserv.

Findings: Specific research proposals were generated in three States (Washington, Oklahoma, and Virginia), and an R01 application was submitted to the National Institute of Mental Health to develop risk-adjustment models using each State's respective administrative databases. Another result of this conference is funding from the Evaluation Center at the Center for Human Services Research Institute (HSRI) to develop a risk-adjustment toolkit, an instructional CD, and an interactive Internet risk adjustment workshop to accompany the toolkit and CD. Additionally, a second conference on the issue of risk adjustment was funded by the Oklahoma Department of Mental Health and Substance Abuse Services. The meeting summary is available for a fee from the National Technical Information Service, 800-553-NTIS. The NTIS accession no. is PB2002-102930.

PI: Nancy E. Lombardo, Ph.D., Hebrew Rehabilitation Center for the Aged, Boston (Small Conference Grant)
Grant No.: R13 HS07696
Grant Period: 4/1/93-9/30/95
Title: Overcoming Barriers to Mental Health Care of Nursing Home Residents

Description: This conference aimed to encourage research concerning: the status of and barriers to mental health care in nursing homes; the effects of Federal policies on access, treatment, costs, quality, staffing alternatives, and financing of mental health care to nursing home residents; the projected impacts of changes in demographics, Federal budget crisis situation, financing, and private and government funding sources on mental health care in nursing homes; and the research agenda needed to address the needs and advances made in care and treatment, program design, and financing of mental health services to individuals in nursing homes. The conference also intended to develop policy options and recommendations to improve mental health care of nursing home residents.

Findings: A policy brief was published in 1995 in the Journal of Mental Health and Aging. It describes the activities of the conference and the specific recommendations that were developed as they related to the central themes of the meeting: financing and reimbursement, treatment and practice, and service delivery and quality management. Also addressed in the brief are the prevalence of mental health problems in nursing homes, treatment rates, and treatment gaps. Some descriptions of model programs are included, as well as past Federal and State policies relevant to mental health problems in nursing homes.

PI: Michael Marmot, M.D., University College London, United Kingdom
Grant No.: R01 HS06516
Grant Period: 9/30/90-3/31/96
Title: Social Factors Influencing Medical Outcome Measures

Description: The Whitehall II project is a prospective study that examined causes of socioeconomic inequalities in health among 10,314 male and female civil servants ages 35-55 in London. In order to supplement that study, AHRQ funded this project to measure health-related functioning. The objectives were to: (1) validate the MOS-General Health Survey in a general population sample in Britain; (2) examine the relationship between functional status and other self-reported and measured components of health; (3) examine the relationships among socioeconomic status, functional status, and perceived well-being; (4) assess the impact on functional status and perceived well-being of features of lifestyle, work environment, social networks and types of social support, and socioeconomic circumstances, both current and during childhood; and (5) establish a cohort in which the prospective significance of functional status can be investigated. Subsequent sickness absence, major morbidity, and mortality were related to the baseline measures of functional status.

Findings: Although it has commonly been believed that men's identities are tied more to their roles at work and women's to their roles at home, it has now been determined that the level of control at home and work affect men and women differently, but social position affects the extent of the impact. Women who had little latitude for decisionmaking at work had more than a 40-percent risk for depression, and men with the same lack of control had a 50-percent greater risk for depression than women and other men who had greater latitude for decisionmaking at work. Both genders in middle employment grades with low control were at greater risk for depression and anxiety than those in lower or higher grades. Both genders with low control at home were also at greater risk for depression and anxiety. Women with low control had over twice the risk for depression of women with high control, even after adjusting for marital status, number of children, and caregiving status. In addition, women in the lowest employment grade with low control at home had significantly higher risk for depression than men across all grades and women in higher grades. Men in the highest grade with low control at home were at higher risk for anxiety than men in lower grades, while women in the lowest grade had a higher risk for anxiety than women in higher grades. Overall, men and women in the lowest civil service grades had the highest risk for depression and anxiety. Factors such as social support, life events, and material problems may be influential. Differences in the health of individuals reflect inherent features of the societies in which they live.

The way a society organizes itself and delivers well-being to its members are major determinants of health. Social, economic, and political factors have an important influence on health and longevity. Social position and lifestyle only partially explain ill health. Psychosocial factors, such as a sense of isolation, deprivation, or loss of control, are also important. Governments can reduce health inequalities by ensuring that all policies are assessed for their potential impact on the health of all sectors of society.

Male British civil servants who consume 30 or more units of alcohol (a unit is equivalent to a glass of wine or beer or one ounce of spirits) a week have 12-percent more short work absences (1 week or less) than those who drink 10 or fewer units a week. Male employees who drink more than once a day have 18-percent more short work absences than those who drink once or twice a week. This study showed that work absences longer than 1 week were lowest in men who drank 11-15 units of alcohol each week and were highest in men who either did not drink at all or drank heavily. Women's long and short work absences were not related to how much or how often they drank, with one exception. Women who never drank had 20 percent more short absences and 25 percent more long absences than women who drank once or twice a week. Men and women in the lower employment grades were more likely to be nondrinkers, while those in top administrative grades were more likely to drink alcohol at least once a day. Overall, men were more frequent and heavier drinkers than women, but these differences were less marked in higher employment grades.

PI: Ruvanee M. Pietersz, M.A., University of Chicago (Dissertation Grant)
Grant No.: R03 HS10565
Grant Period: 9/30/99-6/30/01
Title: Psychosocial Interventions for Metastatic Breast Cancer

Description: The goal of this dissertation was to give a descriptive account of the progressive psychosocial effects of metastatic breast cancer and to examine the impact of interventions to prevent psychosocial deterioration. The study analyzed data from an existing expressive-supportive group psychotherapy intervention study, from an Internet support group, and from a control no-intervention group to assess the effects of intervention on psychosocial factors in women with metastatic breast cancer.

Findings: This dissertation is not available at this time.

PI: Xinhua S. Ren, Ph.D., New England Medical Center Hospitals, Inc.
Grant No.: R03 HS09352
Grant Period: 9/30/96-3/31/98
Title: Assessment of Functional Health Status Among Elderly Chinese

Description: The purpose of this research was to develop and test new measures of functional health status among elderly Chinese Americans. The researchers tested 219 elderly Chinese in Boston, using the newly developed Chinese version of the SF-36 health status questionnaire to explore how the elderly Chinese perceive their own health and how their perceptions of health status, as well as sociocultural factors, influence their health behaviors.

Findings: Although those interviewed perceived similar or better physical health compared with the norm for other U.S. populations, they reported worse mental health. Yet elderly Chinese are less likely to use mental health services because of the stigmatization of mental problems and their fear of disgracing the family.

PI: John W. Robinson, Johns Hopkins University (Fellowship Grant)
Grant No.: F32 HS00068
Grant Period: 9/1/93-8/31/94
Title: Health Services Research and Biostatistics

Description: The purpose of this study was to examine the factors influencing community-based primary care physician (PCP) recognition of mental health problems in patients presenting solely somatic reasons for visiting. The researchers reviewed 308 audiotaped interviews between patients indicating significant psychological distress and their respective PCPs to measure three effects on physician recognition of mental health problems. These effects were: (1) the effect of patient self-assessed emotional condition, measured independently from the encounter with the physician, on patient disclosure of psychological symptoms or psychosocial concerns later in the visit, subsequent to presentation of solely somatic reasons for the visit; (2) the effect of physician inquiry about psychological symptoms or psychosocial concerns on patient disclosure of such symptoms and concerns; and (3) the effect of patient disclosure of psychological symptoms or psychosocial concerns later in the visit, subsequent to presentation of solely somatic reasons for the visit.

Findings: Patient disclosure of psychosocial problems occurred in 51 percent of the visits and in 67 percent of the visits with prior psychosocial inquiry by the PCPs. The likelihood of disclosure was increased by prior inquiry, greater patient-physician familiarity, and greater severity of patient psychological distress. Sixty percent of patients who disclosed psychosocial problems were counseled by their PCP, and 30 percent of those patients who disclosed psychosocial problems were prescribed psychotropic medications. The likelihood of counseling for patients who disclosed psychosocial problems was lowest for new patients and otherwise inversely related to the number of previous visits. The counseling sessions, although brief, accounted for significant increases in visit durations. The researchers conclude that if PCPs inquire, especially by merely adding one or two questions about mood or interpersonal problems to their clinical interviews, most psychologically distressed, somatically presenting patients will disclose psychosocial problems.

PI: Meredith B. Rosenthal, Ph.D., Harvard Medical School (Dissertation Grant)
Grant No.: R03 HS09660
Grant Period: 9/30/97-9/29/98
Title: Provider Risk Sharing in Managed Care

Description: This research explored an increasingly prevalent and controversial way of containing costs in health plans: risk sharing with providers. This research examined impacts on utilization and outcome related to the design of risk-sharing contracts within a managed behavioral health organization (MBHO) as well as their impact in an outpatient mental health setting. The researcher utilized claims data, clinical and discharge data, and organizational data on the managed care organization and approximately 300 group practices with which it contracts.

Findings: Behavioral health providers reduce the duration of mental health therapy, given financial incentives to do so. When an MBHO changed the way it contracted for outpatient mental health care with its network providers from a fee-for-service system to a case-rate system (fixed payment for all covered treatment per patient), mental health visits went down 25 percent. It also appears that providers substitute "free" services, such as referrals to self-help groups and community care, when additional therapy becomes costly. No impact on mental health status was found.

PI: Richard Scheffler, Ph.D., University of California, Berkeley (UCB), and Harold Luft, Ph.D., University of California, San Francisco (UCSF)
Grant No.: T32 HS00026
Grant Period: 9/1/91-8/31/99
Title: Health Services Research Training Program

Description: This broad-based interdisciplinary program used the resources of both UCB and UCSF to train health services researchers at both the pre- and postdoctoral levels. The training program has been part of major health services research training efforts and provided one of the richest health services research educational environments in the United States. The long-term objectives of the training program were to train the Nation's most qualified health services researchers in order that they may make significant contributions to the knowledge of health services issues and toward resolving current health policy crises. The training program gave trainees an in-depth understanding of the U.S. health care system and the ability to deal with the system from social, political, and economic perspectives. The training occurred through a combination of courses, seminars, mentored hands-on research, and one-on-one career advising. All trainees received rigorous methodological and quantitative preparation that has enabled them to conduct important interdisciplinary health services research and to make contributions toward understanding the policy implications of the issues.

Findings: Implementation of the State-Local Program Realignment Act in California in 1991, which decentralized the State's mental health system, enhanced access to inpatient and outpatient care for patients with the most severe mental illness. The impact of decentralization on patients with less severe diagnoses was mixed. With funds allocated directly to local governments to provide mental health services, both inpatient and outpatient service use increased significantly for patients with severe diagnoses and fell significantly for those with mild diagnoses. Patients with schizophrenia, mood disorders, other psychotic disorders, substance use disorders, and personality disorders received significantly more outpatient treatment. During the realignment, nearly 1 percent of patients with severe mental illness were shifted from State hospitals to community-based services, which may explain their increased use of outpatient services. Also, fewer patients with substance use disorders were hospitalized, and more patients with anxiety disorders were treated as outpatients. It has long been argued that substance abuse and anxiety disorders can be treated efficiently on an outpatient basis. Overall, the level of use of inpatient care after realignment was not cut as severely as one might expect. Patients with schizophrenia or other psychotic disorders received significantly more inpatient treatment. Outpatient services increased for patients with severe diagnoses and met the level of need for patients with most mild diagnoses. After realignment, the treatment cost per inpatient was significantly higher, suggesting that the sickest patients continued to receive expensive services when necessary. However, outpatient costs per user were significantly lower for all diagnoses, probably as a result of service contracting prompted by the realignment program.

PI: Jinah K. Shin, D.N.S.C., Columbia University (Fellowship Grant)
Grant No.: F32 HS00149
Grant Period: 9/1/00-8/31/02
Title: Utilization of Mental Health Services by Asian or Pacific Islander Americans

Description: This study is investigating the occurrence of ethnic differences in the utilization of inpatient mental health services and determining the factors influencing utilization by Asian or Pacific Islander Americans as compared to other ethnic groups. The researcher is analyzing data on admissions to inpatient psychiatric services in New York State from 1995 to 1998 as available in the Statewide Planning and Research Cooperative System (SPARCS).

Findings: No findings are available at this time.

PI: Christine S. Spencer, Johns Hopkins University (Fellowship Grant)
Grant No.: F32 HS00080
Grant Period: 9/30/93-9/29/95
Title: Determinants of Structure of the Mental Health System

Description: The purpose of this study was to develop theoretical and empirical models to describe the motivation for the availability and organization of mental health resources. Specifically, the researchers intended to analyze the structure of State mental hospitals and the level of decentralization of the community mental health system. The researchers used an existing data set developed specifically to explain the factors influencing State-level decisionmaking.

Findings: A literature review of relevant mental health and public economics material was completed. Work on a model of government determinants of allocation of public capital resources for the mental health sector was begun. Also, progress was made in the assembly of the statewide data set, including demographic, fiscal, organizational, and mental health resource data.

PI: Annie G. Steinberg, M.D., Children's Seashore House, Philadelphia (Small Conference Grant)
Grant No.: R13 HS09813
Grant Period: 4/1/98-6/30/99
Title: Mental Health Services Delivery in Primary and Specialty Care Settings

Description: This conference provided a forum for discussion of significant issues impacting the delivery of mental health care services in the primary care setting and the relationship to specialty care settings. The current state of research and evidence was also discussed. Conference proceedings and products included a literature review and brief presentations covering a number of topics, followed by a round-table discussion, and a monograph of the conference proceedings.

Findings: Children's Mental Health: The Changing Interface Between Primary and Specialty Care includes input from many of the conference's participants and addresses the following topics: (1) an evidence-based, best-practices approach to the primary care/specialty care relationship as it pertains to child mental health; (2) underrecognition of the mental health problems that affect children and adolescents and the poor outcomes that often occur; and (3) professional responsibilities across systems of care to avoid duplication, address shortages, and define health services research priorities. The monograph also presents implications for action and a series of recommendations for children's mental health services research topics spanning the next 5 years.

An issue brief on children's mental health issues, entitled Leonard Davis Institute of Health Economics Issue Brief—Children's Mental Health: Recommendations for Research, Practice, and Policy, was also published. It covers the following topics: (1) changes in children's mental health services over the past decade; (2) increases in psychotropic drug use in children; (3) effects of managed care on the delivery of mental health services to children; (4) resources needed by primary care providers to identify and address children's mental health needs; (5) a promising system of care model; (6) a children's mental health research agenda; and (7) policy implications associated with meeting the need for mental health services among children. Both the monograph (AHRQ Publication No. 00-R040) and the issue brief (AHRQ Publication No. 00-R042) are available from the AHRQ Publications Clearinghouse.

PI: John E. Ware, Jr., Ph.D., New England Medical Center Hospitals, Inc.
Grant No.: R01 HS06073
Grant Period: 1/1/88-12/31/91
Title: Variations in Physicians' Practice Style and Outcomes of Care

Description: The purpose of this grant was to supplement the collection and analysis of data from the Medical Outcome Study (MOS), an ongoing research effort designed to determine whether the health outcomes of patients with prevalent and treatable chronic conditions—depression, diabetes, hypertension, and heart disease—vary in relation to the kind of primary health care practice they use. Researchers investigated the extent of practice-style variation among three types of primary care providers—health maintenance organizations, multispecialty group practices, and solo fee-for-service medical practices—the reasons for the variations, and their implications for patient outcomes.

Findings: The SF-36, a 36-item short form, was developed in order to survey health status for the MOS. This form was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The MOS is a multi-item scale that assesses eight health concepts, including one on general mental health (psychological distress and well-being). Using the MOS, researchers also were able to corroborate and strengthen previous findings that depression has considerable importance in clinical and social areas. Depression is found to be just as disabling and limiting as many other chronic, common medical conditions. There was clear evidence that dysthymia patients had the worst outcomes, while even patients with subthreshold depressive symptoms had a high chance of experiencing a major depression over 2 years.

Rates of detection in primary care settings were found to be low. If depressed patients were seen by a mental health specialist, there was a roughly 78-87 percent rate of detection, while patients seen by medical specialists had depression diagnosed 45-51 percent of the time. There were differences in detection based on payment types. Patients were more likely to receive a diagnosis if they received fee-for-service care.

Depressed patients followed by psychiatrists were more often treated with antidepressants than patients of other clinicians, but over time, the use of this treatment in prepaid compared to fee-for-service care dropped dramatically. Psychiatrists treated the sicker patients.

PI: Norma C. Ware, Ph.D., Harvard University
Grant No.: R01 HS10335
Grant Period: 9/30/99-9/29/01
Title: Cultural Relevance of a Continuity of Care Measure

Description: The purpose of this study was to determine the cultural relevance of a new measure of continuity of care in mental health services for blacks, whites, and Puerto Ricans. This study built on a project funded by the National Institute of Mental Health in which 400 individuals with serious mental illness were interviewed. The researchers evaluated different mental health scales and then compared them among the three ethnic groups.

Findings: No findings are available at this time.

PI: Milton C. Weinstein, Ph.D., Harvard University (Training Grant)
Grant No.: T32 HS00020
Grant Period: 9/1/86-6/30/03
Title: Harvard University Health Services Research Training

Description: This grant was funded to aid in the training of various investigators at the Harvard University Health Services Research Training Program in areas of health services research. Areas of research include quality of care, access, outcomes, cost-effectiveness, medical technology assessment, and AIDS policy. Mental-health- specific research and findings from this grant include: (1) a study of the determinants of and risk factors associated with death for adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993; (2) a 1995 survey of 2,003 U.S. physicians to determine the impact of managed care plans' incentives and constrains upon delivery of care; (3) a review of data from the 1991 Medicare Current Beneficiary Survey to examine the relationship between psychiatric disorders—including affective, anxiety, psychotic, organic, substance abuse, and/or personality disorders—and care satisfaction in a national sample of elderly and disabled patients; and (4) a study of the results of the Massachusetts Group Insurance Commission's adoption in 1992 of a carve-out program to cover mental health/substance abuse services.

Findings: (1) In regard to deaths of adults in the homeless program, homicide was the leading cause of death among men aged 18-44 years, followed by traumatic injury and poisoning (including alcohol- and drug-related deaths). Homeless persons may be at increased risk for pneumonia and influenza—frequent causes of death—because of a high prevalence of alcoholism, smoking, HIV infection, and chronic disease. The high risk of death from homicide and accidental injury is a predictable result of poverty, substance abuse, and living on the streets. The increased number of deaths during the first week of each month coincides with the arrival of disability checks, which often leads to a flurry of substance abuse, injuries, and deaths. The researchers suggest consideration of improved alcohol and drug treatment programs for homeless persons. Homeless individuals typically suffer from substance abuse, psychiatric disorders, and/or major medical illnesses. The risk of death was about twice as high among individuals with a history of abusing alcohol or cocaine and three times as high for those with a history of opiate abuse or injection drug use. (2) In the study of the impact of managed care, only about 3 percent of the types of care studied were ultimately denied, with coverage most frequently denied for mental health treatment, substance abuse treatment, and referral to a specialist of choice. (3) In the review of Medicare data, it was found that aged and disabled Medicare beneficiaries with psychiatric disorders are significantly less likely than those without disorders to be satisfied with the overall quality of their health care. This group is particularly apt to be dissatisfied with followup care and physicians' concern for their overall health. However, it is not clear whether psychiatric impairment biases their assessments or whether these patients actually receive lower quality care than similar patients without psychiatric problems. (4) In the study of the carve-out program, researchers found that the carve-out resulted in a 54-percent decrease in total episode costs for individuals with unipolar depression and a 33-percent decrease for those with substance dependence. The researcher suggests that these savings were most likely due to the shift from traditional inpatient care to less intensive and less expensive partial hospitalization services and traditional outpatient care for people with unipolar depression, but he could not determine whether the carve-out arrangement resulted in a shift away from facility and outpatient treatments toward use of psychotropic drugs.

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