Development and Implementation of a Telemental Health Program for Caregivers in a Children's Hospital Setting.

Introduction: Caregivers of children with chronic illness, such as hematology-oncology conditions, face numerous stressors, and a subset experience persistent distress and poor psychological outcomes. Many logistical and ethical barriers complicate the provision of mental health care to caregivers in children's hospital settings. Telemental health (TMH) is one method to increase access and reduce barriers. Methods: A partnership was established with an outside TMH agency to provide mental health care to caregivers of children with hematology-oncology conditions. Development and implementation strategies are described, and feasibility was measured on four dimensions. Results: One hundred twenty-seven (n = 127) caregivers were referred for TMH services in the first 28 months of program implementation. Of the total, 63/127 (49%) received TMH services for at least one session. Most caregivers had a child in active medical treatment (89%). A small portion (11%) of caregivers were bereaved or had a child in hospice care. Program feasibility was enhanced by hospital leadership support and availability of staffing, financial, and technology resources. Available resources also contributed to the practicality of program development and swift implementation and integration within the defined hospital system. Discussion: Partnership with an outside TMH agency increased access to care and reduced barriers to treating caregivers in a children's hospital setting. Offering mental health interventions to caregivers aligns with evidence-based standards of care. Future research will elucidate caregiver satisfaction with this modality of treatment and whether use of TMH reduces disparities in caregiver receipt of mental health care in children's hospital settings.

Relationship between skeletal maturity indicators and dental calcification stages in a sample pediatric population.

Context: Human growth shows considerable variation. In addition to constitutional differences in the timing of maturation, there are diseases, systemic disorders and environmental factors that may affect a child's physiologic maturity. Interrelationships among skeletal, somatic and sexual maturity have been shown to be consistently strong. The study was conducted to evaluate the relationship between dental calcification stages and skeletal maturity indicators. Materials and Methods: The hand wrist radiographs, the lateral cephalogram and the orthopantomogram (OPG) of 120 patients (60 males and 60 females, age group 8-14 years) were taken. The hand wrist radiographs were analyzed using Fishman's skeletal maturity index (SMI), and the cephalograms analyzed by cervical vertebrae maturation (CVM) by Baccetti. OPG was analyzed according to the Demirjian's system. Result: On assessment, cervical vertebrae maturation indicator (CVMI) staging showed significant results with a correlation coefficient of 0.716 being the highest in canines in males while assessment of dental calcification stages and its comparison with skeletal maturity indicator showed insignificant results. The correlation coefficient values were 0.11, 0.09, 0.09 and 0.13 for canine, first premolar, second premolar and second molar respectively. Conclusion: There is a strong correlation between the maturation stage of cervical vertebrae and calcification stages of canine, first premolar, second premolar and second molar as determined by Demirjian's method.

Self-compassion Intervention for Parents of Children with Developmental Disabilities: A Feasibility Study.

Objectives: Parents of children with developmental disabilities (DDs) experience greater psychological distress (e.g., stress and depression) compared to parents of children without DDs. Self-compassion (i.e., responding with compassion to oneself during times of stress and difficulty) is associated with greater self-care as well as lower levels of stress, depression, and internalized stigma among parents of children with DDs. In this study, we tested the feasibility of a 4-week brief, asynchronous, online intervention targeting self-compassion among parents of children with DDs. Methods: Participants were fifty parents (48 mothers; 2 fathers) of children with DDs. Participants' ages ranged from 25 to 62 years (M = 42.1 years, SD = 7.9 years), and 88% of participants had one child with a DD, and the remaining parents had two or more children with DDs. Child diagnoses included Down syndrome, autism spectrum disorder, and intellectual disability. Feasibility was assessed in five domains (i.e., acceptability, demand, implementation, practicability, and limited efficacy) using a combination of self-report measures, qualitative feedback, and data on attrition. Results: Most parents (84%) completed ≥ 3 modules, and 74% completed all four modules. Almost all parents (> 90%) reported that they would recommend the intervention to others. Paired-samples t-tests demonstrated significant pre-intervention to post-intervention increases in self-compassion and well-being, and significant reductions in parent depression and stress. Conclusions: Overall, data support feasibility of the 4-week intervention targeting parent self-compassion and provide preliminary efficacy data that need to be followed up in a larger randomized control trial.

Associations among co-occurring medical conditions and cognition, language, and behavior in Down syndrome.

BACKGROUND: Specific medical conditions are more prevalent in Down syndrome (DS) compared to the general population. Medical heterogeneity has also been hypothesized to contribute to variability in outcomes in DS. AIMS: This project aimed to examine the association between medical conditions (i.e., gastrointestinal issues, hearing loss, vision problems, and congenital heart defects) and cognition, language, and behavior in children and adolescents with DS. METHODS AND PROCEDURES: Participants were 73 children and adolescents with DS, ages 6-17 years (M = 12.67, SD = 3.16). Caregivers reported on participants' medical conditions, social behaviors, maladaptive behaviors, and executive function. Child cognitive abilities were also assessed. OUTCOMES AND RESULTS: Of the 73 participants, 34.2% had gastrointestinal issues, 12.3% had uncorrected hearing loss, 26.0% had uncorrected vision problems, and 31.5% had congenital heart defects. Participants with gastrointestinal issues had significantly more challenges with social behaviors, maladaptive behaviors, and executive function compared to those without gastrointestinal issues. CONCLUSIONS AND IMPLICATIONS: The associations identified between gastrointestinal issues and caregiver-reported behavioral characteristics in youth with DS contributes to our understanding of the interrelation between co-occurring medical conditions and child outcomes and has implications for approaches to care for individuals with DS.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network.

OBJECTIVE: The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems. METHODS: Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings. RESULTS: Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64). CONCLUSIONS: There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

Psychiatric comorbidity and 30-day readmissions after hospitalization for heart failure, AMI, and pneumonia.

OBJECTIVE: In 2012, the Centers for Medicare and Medicaid Services implemented a policy that penalizes hospitals for "excessive" all-cause hospital readmissions within 30 days after discharge from an index hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. The aim of this study was to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions following hospitalizations for HF, AMI, and pneumonia. METHODS: Data from 2009-2011 were derived from the HMO Research Network Virtual Data Warehouse of 11 health systems affiliated with the Mental Health Research Network. All index inpatient hospitalizations for HF, AMI, and pneumonia were captured (N=160,169). Psychiatric diagnoses for the year prior to admission were measured. All-cause readmissions within 30 days of discharge were the outcome variable. RESULTS: Approximately 18% of all individuals with index inpatient hospitalizations for HF, AMI, and pneumonia were readmitted within 30 days. The rate of readmission was 5% greater for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (21.7% and 16.5%, respectively, p<.001). Depression, anxiety, and dementia were associated with more readmissions of persons with index hospitalizations for each general medical condition and for all the conditions combined (p<.05). Substance use and bipolar disorders were linked with higher readmissions for those with initial hospitalizations for HF and pneumonia (p<.05). Readmission rates declined overall from 2009 to 2011. CONCLUSIONS: Individuals with HF, AMI, and pneumonia experience high rates of readmission, but psychiatric comorbidities appear to increase that risk. Future interventions to reduce readmission should consider adding mental health components.

Chronic opioid use emerging after bariatric surgery.

PURPOSE: Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery. METHODS: This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days' supply. RESULTS: Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days' supply was strongly associated with chronic use post-surgery (1-29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24-2.88]; 90-119 days OR, 14.29 [95%CI, 6.94-29.42] compared with no days). Other factors associated with increased likelihood of post-surgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39-3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12-2.50]), and tobacco (OR, 1.44 [95%CI, 1.03-2.02]). Older age (OR, 0.84 [95%CI, 0.73-0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25-0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery. CONCLUSIONS: Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery.

Chronic use of opioid medications before and after bariatric surgery.

IMPORTANCE: Obesity is associated with chronic noncancer pain. It is not known if opioid use for chronic pain in obese individuals undergoing bariatric surgery is reduced. OBJECTIVES: To determine opioid use following bariatric surgery in patients using opioids chronically for pain control prior to their surgery and to determine the effect of preoperative depression, chronic pain, or postoperative changes in body mass index (BMI) on changes in postoperative chronic opioid use. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in a distributed health network (10 demographically and geographically varied US health care systems) of 11,719 individuals aged 21 years and older, who had undergone bariatric surgery between 2005 and 2009, and were assessed 1 year before and after surgery, with latest follow-up by December 31, 2010. MAIN OUTCOMES AND MEASURES: Opioid use, measured as morphine equivalents 1 year before and 1 year after surgery, excluding the first 30 postoperative days. Chronic opioid use is defined as 10 or more opioid dispensings over 90 or more days or as dispensings of at least a 120-day supply of opioids during the year prior to surgery. RESULTS: Before surgery, 8% (95% CI, 7%-8%; n = 933) of bariatric patients were chronic opioid users. Of these individuals, 77% (95% CI, 75%-80%; n = 723) continued chronic opioid use in the year following surgery. Mean daily morphine equivalents for the 933 bariatric patients who were chronic opioid users before surgery were 45.0 mg (95% CI, 40.0-50.1) preoperatively and 51.9 mg (95% CI, 46.0-57.8) postoperatively (P < .001). For this group with chronic opiate use prior to surgery, change in morphine equivalents before vs after surgery did not differ between individuals with loss of more than 50% excess BMI vs those with 50% or less (>50% BMI loss: adjusted incidence rate ratio [adjusted IRR, 1.17; 95% CI, 1.07-1.28] vs ≤50% BMI loss [adjusted IRR, 1.03; 95% CI, 0.93-1.14] model interaction, P = .06). In other subgroup analyses of preoperative chronic opioid users, changes in morphine equivalents before vs after surgery did not differ between those with or without preoperative diagnosis of depression or chronic pain (depression only [n = 75; IRR, 1.08; 95% CI, 0.90-1.30]; chronic pain only [n = 440; IRR, 1.17; 95% CI, 1.08-1.27]; both depression and chronic pain [n = 226; IRR, 1.11; 95% CI, 0.96-1.28]; neither depression nor chronic pain [n = 192; IRR, 1.22; 95% CI, 0.98-1.51); and P values for model interactions when compared with neither were P = .42 for depression, P = .76 for pain, and P = .48 for both. CONCLUSIONS AND RELEVANCE: In this cohort of patients who underwent bariatric surgery, 77% of patients who were chronic opioid users before surgery continued chronic opioid use in the year following surgery, and the amount of chronic opioid use was greater postoperatively than preoperatively. These findings suggest the need for better pain management in these patients following surgery.

The effect of bariatric surgery on psychiatric course among patients with bipolar disorder.

OBJECTIVE: Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder. METHODS: A matched cohort study (2006-2009) with mean follow-up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups. RESULTS: A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow-up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83-1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (-0.4 visits/year, 95% CI: -0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: -0.1 to 1.0). CONCLUSIONS: Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.

Obesity and mental illness: implications for cognitive functioning.

A priority research and clinical agenda is to identify determinants of cognitive impairment in individuals with neuropsychiatric disorders (NPD). The bidirectional association between NPD and cognitive performance has been reported to be mediated and/or moderated by obesity in a subset of individuals. Obesity can be conceptualized as a neurotoxic phenotype among individuals with NPD as evidenced by alterations in the structure and function of neural circuits and disseminated networks, diminished cognitive performance, and adverse effects on illness trajectory. The neurotoxic effect of obesity provides a rationale for screening, treating, and preventing obesity in neuropsychiatric populations. Research endeavors that aim to refine mediators and moderators of this association as well as novel strategies to reverse the injurious process of obesity on cognition are warranted.

A comparison of lifestyle and behavioral cardiovascular disease risk factors between Asian Indian and White non-Hispanic men.

OBJECTIVE: We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. DESIGN/SETTING/PARTICIPANTS: Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men's Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). MAIN OUTCOME MEASURES: Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. RESULTS: Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. CONCLUSIONS: We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.

Perceptions of middle school educators in Hawai'i about school-based gardening and child health.

BACKGROUND: Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health. METHODS: Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai'i were conducted. Data were analyzed using a grounded theory approach. RESULTS: Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health. CONCLUSIONS: In order to be effective at obesity prevention, school-based gardening programs in Hawai'i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.

Surgical treatment of morbid obesity among patients with bipolar disorder: a research agenda.

INTRODUCTION: Persons with bipolar disorder (BD) have an increased risk of obesity and associated diseases. Success of current behavioral treatment for obesity in patients with BD is inadequate. METHODS: Existing literature on bariatric surgery outcomes in populations with BD were reviewed, and needed areas of research were identified. RESULTS: Knowledge about bariatric surgery outcomes among patients with BD is limited. Available evidence indicates that bariatric surgery is a uniquely effective intervention for achieving and sustaining significant weight loss and improving metabolic parameters. Notwithstanding the benefits of bariatric surgery in nonpsychiatric samples, individuals with BD (and other serious and persistent mental illnesses) have decreased access to this intervention. Areas of needed research include: (1) current practice patterns; (2) metabolic course after bariatric surgery; (3) psychiatric course after bariatric surgery; and (4) mechanisms of psychiatric effect. CONCLUSION: The considerable hazards posed by obesity in BD, as measured by illness complexity and premature mortality, provide the basis for hypothesizing that bariatric surgery may prevent and improve morbidity in this patient population. In addition to physical health benefits, bariatric surgery may exert a robust and favorable effect on the course and outcome of BD and reduce obesity-associated morbidity, the most frequent cause of premature mortality in this patient population.

Heterogeneity of diabetes outcomes among asians and pacific islanders in the US: the diabetes study of northern california (DISTANCE).

OBJECTIVE: Ethnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted. RESULTS: Pacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites. CONCLUSIONS: Incidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.

Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE).

BACKGROUND: A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown. OBJECTIVE: To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician. DESIGN: Cross-sectional, observational study using data from the 2005-2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%). KEY RESULTS: The unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53-1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04-2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03-3.80). CONCLUSIONS: Language barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

Mental health services utilization among women experiencing intimate partner violence.

OBJECTIVE: To examine the patient and provider characteristics associated with utilization of mental health services (MHS) among women experiencing intimate partner violence (IPV). STUDY DESIGN: Cross-sectional study among 6870 women aged 18 to 65 years with first IPV identification between May 2004 and December 2009 in Kaiser Permanente Northern California. METHODS: Utilization of MHS within 60 days after first IPV identification was determined. Multivariate generalized estimating equation logistic regression models that controlled for patient and provider characteristics were used to determine predictors of utilization. RESULTS: Thirty-seven percent of women utilized MHS. In multivariate generalized estimating equation models, the strongest predictor of utilization was electronic referral (odds ratio [OR], 4.40; 95% confidence interval [CI], 3.66-5.28). Odds of utilization were lower among black (OR, 0.71; 95% CI, 0.57-0.89), Latina (OR, 0.62; 95% CI, 0.41-0.95), and Spanish-speaking (OR, 0.71; 95% CI, 0.57-0.89) patients and were higher among those with prior posttraumatic stress disorder (OR, 2.38; 95% CI, 1.17-3.44) or depression (OR, 1.35; 95% CI, 1.17-1.57). Emergency department identification of IPV was associated with lower odds of MHS utilization (OR, 0.46; 95% CI, 0.37-0.59), while older provider identification of IPV was associated with higher odds of MHS utilization (OR, 1.33; 95% CI, 1.07-1.65). CONCLUSIONS: Additional training for providers, particularly those who are younger or are practicing in emergency departments, may be needed to increase rates of MHS utilization among patients affected by IPV. Addressing language barriers to care and cultural appropriateness may improve MHS utilization.

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study.

OBJECTIVE: To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions. METHODS: Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination. RESULTS: Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients. CONCLUSIONS: Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians. PRACTICE IMPLICATIONS: Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.

The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study.

BACKGROUND: Use of four or more prescription medications is considered a risk factor for falls in older people. It is unclear whether this polypharmacy-fall relationship differs for adults with diabetes. OBJECTIVE: We evaluated the association between number of prescription medications and incident falls in a multi-ethnic population of type-2 diabetes patients in order to establish an evidence-based medication threshold for fall risk in diabetes. DESIGN: Baseline survey (1994-1997) with 5 years of longitudinal follow-up. PARTICIPANTS: Eligible subjects (N = 46,946) had type-2 diabetes, were >or=18 years old, and enrolled in the Kaiser Permanente Northern California Diabetes Registry. MEASUREMENTS AND MAIN RESULTS: We identified clinically recognized incident falls based on diagnostic codes (ICD-9 codes: E880-E888). Relative to regimens of 0-1 medications, regimens including 4 or more prescription medications were significantly associated with an increased risk of falls [4-5 medications adjusted HR 1.22 (1.04, 1.43), 6-7 medications 1.33 (1.12, 1.58), >7 medications 1.59 (1.34, 1.89)]. None of the individual glucose-lowering medications was found to be significantly associated with a higher risk of falls in predictive models. CONCLUSIONS: The prescription of four or more medications was associated with an increased risk of falls among adult diabetes patients, while no specific glucose-lowering agent was linked to increased risk. Baseline risk of falls and number of baseline medications are additional factors to consider when deciding whether to intensify diabetes treatments.