The incremental direct costs associated with behavioral symptoms in AD.

OBJECTIVE: To determine the incremental costs associated with behavioral symptoms in patients with AD. METHODS: A total of 128 patients with probable AD were enrolled into this study. Cognitive function and extrapyramidal features were assessed in patients with AD. Caregivers were interviewed to determine use of health care services, receipt of unpaid care, severity of behavioral symptoms (Neuropsychiatric Inventory [NPI]), and comorbid medical conditions in patients with AD. Healthcare utilization data were multiplied by unit costs to estimate direct formal costs. Unpaid caregiving hours were multiplied by an hourly wage to estimate direct informal costs. The annual incremental direct costs of additional behavioral symptoms were estimated with multiple regression equations. RESULTS: Annual, direct costs were significantly higher in patients with AD at or above the median score on the NPI (high NPI group), after adjusting for group differences in severity of cognitive impairment and comorbid conditions. Patients in the high NPI group had formal costs between US$3,162 and US$5,919 higher than the low NPI group and total direct costs between US$10,670 and US$16,141 higher, depending on the severity of cognitive impairments. Models for the entire sample estimated that a one-point increase in the NPI score would result in an annual increase of between US$247 and US$409 in total direct costs, depending on the value of unpaid caregiving. CONCLUSIONS: Behavioral symptoms in patients with AD significantly increase direct costs of care.

Geriatric mental health services research: Strategic Plan for an Aging Population: Report of the Health Services Work Group of the American Association for Geriatric Psychiatry.

In November 1999, a working group of the American Association for Geriatric Psychiatry (AAGP) convened to consider strategic recommendations for developing geriatric mental health services research as a scientific discipline. The resulting consensus statement summarizes the principles guiding mental health services research on late-life mental disorders, presents timely and topical priorities for investigation with the potential to benefit the lives of older adults and their families, and articulates a systematic program for expanding the supply of well-trained geriatric mental health services researchers. The agenda presented here is designed to address critical questions in provision of effective mental health care to an aging population and the health policies that govern its delivery.

Nicotine replacement methods on a psychiatric unit.

UNLABELLED: Patients with psychiatric illness smoke more heavily than others in the community. They have more difficulty quitting and have more withdrawal symptoms than others. OBJECTIVE: The purpose of the present study was to examine the utilization of nicotine replacement methods in a population of psychiatric patients. METHOD: In a naturalistic retrospective review, we examined the records of 55 patients who were hospitalized on a smoke-free psychiatric unit. We abstracted the frequency of utilization of nicotine replacement. The rate of utilization was considered a ratio of the number of days utilized to the number of days prescribed. RESULTS: There were 38 patients (69%) who used the transdermal patch, 26 patients (47%) used the inhaler, 4 patients (7%) used nicotine gum, and 2 patients (4%) used the nasal spray. The rate of utilization of the nicotine inhaler (63%) exceeded that of the transdermal nicotine patch (30%) (t = 4.6, p < .0001). CONCLUSION: The hospitalization of smokers with mental illness in smoke-free psychiatric units often leads to further behavioral deterioration. The patients in the present study demonstrated a definite preference for the nicotine inhaler over the transdermal patch. Possible clinical and pathophysiological implications of this finding are discussed.

Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders.

Most primary care physicians do not feel competent to treat alcohol- and drug-related disorders. Physicians generally do not like to work with patients with these disorders and do not find treating them rewarding. Despite large numbers of such patients, the diagnosis and treatment of alcohol- and drug-related disorders are generally considered peripheral to or outside medical matters and ultimately outside medical education. There is substantial evidence that physicians fail even to identify a large percentage of patients with these disorders. Essential role models are lacking for future physicians to develop the attitudes and training they need to adequately approach addiction as a treatable medical illness. Faculty development programs in addictive disorders are needed to overcome the stigma, poor attitudes, and deficient skills among physicians who provide education and leadership for medical students and residents. The lack of parity with other medical disorders gives reimbursement and education for addiction disorders low priority. Medical students and physicians can also be consumers and patients with addiction problems. Their attitudes and abilities to learn about alcohol- and drug-related disorders are impaired without interventions. Curricula lack sufficient instruction and experiences in addiction medicine throughout all years of medical education. Programs that have successfully changed students' attitudes and skills for treatment of addicted patients continue to be exceptional and limited in focus rather than the general practice in U.S. medical schools. The authors review the findings of the literature on these problems, discuss the barriers to educational reform, and propose recommendations for developing an effective medical school curriculum about alcohol- and drug-related disorders.

Using case vignettes to train clinicians and utilization reviewers to make level-of-care decisions.

Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function. This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Training tomorrow's clinicians today--managed care essentials: a process for curriculum development.

OBJECTIVE: To develop a managed care curriculum for primary care residents. DESIGN: This article outlines a 4-stage curriculum development process focusing on concepts of managed care organization and finance. The stages consist of: (1) identifying the curriculum development work group and framing the scope of the curriculum, (2) identifying stakeholder buy-in and expectations, (3) choosing curricular topics and delivery mechanisms, and (4) outlining the evaluation process. Key elements of building a curriculum development team, content objectives of the curriculum, the rationale for using problem-based learning, and finally, lessons learned from the partnership among the stakeholders are reviewed. RESULTS: The curriculum was delivered to an entering group of postgraduate-year 1 primary care residents. Attitudes among residents toward managed care remained relatively negative and stable over the yearlong curriculum, especially over issues relating to finance, quality of care, control and autonomy of practitioners, time spent with patients, and managed care's impact on the doctor-patient relationship. Residents' baseline knowledge of core concepts about managed care organization and finance improved during the year that the curriculum was delivered. Satisfaction with a problem-based learning approach was high. CONCLUSION: Problem-based learning, using real-life clinical examples, is a successful approach to resident instruction about managed care.

Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity.

BACKGROUND: The validity of outcome report cards may depend on the ways in which they are adjusted for risk. OBJECTIVES: To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method. DESIGN: Analysis of data from a prospective cohort study. SETTING: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital. PATIENTS: Sequential patients presenting in the emergency department with acute congestive heart failure. MEASUREMENTS: Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index). RESULTS: The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment. CONCLUSIONS: Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.

Substance dependence and the use of pro re nata anxiolytic/hypnotic drugs in a hospital setting.

Patients hospitalized for treatment of psychiatric illness commonly receive pro re nata (p.r.n.) anti-anxiety and hypnotic agents. The relationship between illicit drug use and p.r.n. anti-anxiety/hypnotic drug use in hospitalized psychiatric patients has not been extensively examined. The purpose of the present study was to examine this relationship. A retrospective review of 99 randomly selected hospitalized patients abstracted information regarding the utilization of p.r.n. anxiolytic and hypnotic medications. Seventy percent of the patients surveyed evidenced substance dependence. The substance users utilized p.r.n. anxiolytics (t = 2.29, df = 81, p < .05) and bedtime hypnotics (t = 4.23, df = 90, p < .0001) more frequently than the nonusers. Hospitalized substance abusers appear to continue their substance abuse in the hospital, substituting prescription preparations for illicit drugs. Nevertheless, cumulative literature now suggests that p.r.n. anxiolytic and hypnotic agents play a critical role in the management of aggressive behavior and insomnia in patients hospitalized with psychiatric illness.

Knowledge of mental health benefits and preferences for type of mental health providers among the general public.

OBJECTIVE: The study explored knowledge of mental health benefits and preferences for providers among the general public. METHODS: Analysis was based on a telephone survey of 1,358 adults randomly sampled throughout Michigan in 1997-1998. RESULTS: A large proportion of the respondents were uninformed about their mental health benefits. One-quarter of the sample were unsure if their health plan even included mental health services. Forty-three percent of the sample believed that mental health benefits were equal to benefits provided for general medical services. In answer to a survey question that summarized payment restrictions for psychiatric services and counseling under Medicare, nearly a quarter of older respondents indicated that they would not seek care even when needed. In the overall sample, the majority of respondents said they would initially seek care from their primary care physician for a mental health problem, although responses varied by age. Persons over age 65 were significantly more likely to seek assistance from their primary care doctor than were younger persons. CONCLUSIONS: The general public lacks information about important mental health benefits, and this lack of information may represent a barrier in their seeking care when needed. Given the overriding preference for primary care providers to treat mental health problems, particularly among older adults, mental health issues should be given more attention at all levels of primary care education.

Update of geriatric psychiatry practices among American psychiatrists: Analysis of the 1996 National Survey of Psychiatric Practice.

Using data from the 1996 National Survey of Psychiatric Practice from the American Psychiatric Association (APA), the authors updated information on psychiatrists who are high geriatric providers (HGPs). In 1996, HGPs comprised 18% of the sample. Only 23% reported no geriatric patients in their practice, a 51% reduction from 1988-89; the proportion of HGPs is increasing. HGPs were more often male, minority, international medical school graduates, certified in geriatric psychiatry, and not medical school-affiliated. HGPs worked longer hours/week in direct patient care, had more patient visits/week, and saw more new patients/month, spending more time in hospitals and nursing homes and less time in office-based practice, and seeing more patients with mood disorders, psychotic disorders, and other disorders. Medicare was a proportionally higher payment source. Older psychiatrists were likely to have more patients over age 65. Tracking practice activities of HGPs may help inform policy discussion regarding staffing needs for geriatric patients with late-life mental disorders.

Bright light therapy: improved sensitivity to its effects on rest-activity rhythms in Alzheimer patients by application of nonparametric methods.

Sleep-wake rhythm disturbances in patients with Alzheimer's disease (AD) make a strong demand on caregivers and are among the most important reasons for institutionalization. Several previous studies reported that the disturbances improve with increased environmental light, which, through the retinohypothalamic tract, activates the suprachiasmatic nucleus (SCN), the biological clock of the brain. The data of recently published positive and negative reports on the effect of bright light on actigraphically assessed rest-activity rhythms in demented elderly were reanalyzed using several statistical procedures. It was demonstrated that the light-induced improvement in coupling of the rest-activity rhythm to the environmental zeitgeber of bright light is better detected using nonparametric procedures. Cosinor, complex demodulation, and Lomb-Scargle periodogram-derived variables are much less sensitive to this effect because of the highly nonsinusoidal waveform of the rest-activity rhythm. Guidelines for analyses of actigraphic data are given to improve the sensitivity to treatment effects in future studies.

The impact of OBRA '87 on psychiatric services in nursing homes. Joint testimony of the American Psychiatric Association and the American Association for Geriatric Psychiatry.

The Institute of Medicine has formed a Committee on Improving Quality in Long-Term Care, which is examining the legislative and quality-of-care impact that the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) had on long-term care. The American Psychiatric Association and the American Association for Geriatric Psychiatry were asked to provide written and oral testimony before the Committee in March 1998. The two organizations summarized the key outcomes of OBRA '87 on the psychiatric needs of individuals who receive services in long-term care settings. The written testimony also encouraged the Committee to insist that the long-term care industry develop, test, and refine psychiatric and mental health quality outcome measures for nursing facilities and other long-term care settings.

Mental health services in managed care: quality questions remain.

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.

Vigilance performance in Parkinson's disease and depression.

Patients with Parkinson's disease (PD), patients with Major Depression (MD) and normal control (NC) subjects were administered a continuous performance test (CPT) under neutral and incentive conditions. Patients made more errors than NC subjects with the MD group making a disproportionately large number of omission errors and the PD group tending to make commission errors. Incentive reduced errors across groups. Reaction times were slowest in the MD group. The pattern of findings in patients with MD is consistent with a failure of effort-demanding cognitive processes. In contrast, nondemented patients with PD appeared to have deficiencies in executive control. A previously reported paradoxical effect of incentive on recognition memory performance in depressed patients did not generalize to a vigilance task.

A comparison of visual and computer-generated measures of "seizure quality".

We report on the first direct comparison of measures of seizure quality generated by visual rating of electroencephalographic (EEG) regularity and postictal suppression with THYMATRON-DGx computer-generated indices of seizure energy and postictal suppression. Thirty-two consecutive patients referred for electroconvulsive therapy (166 consecutive treatments) were studied. Blinded ratings of seizure duration, regularity, and postictal EEG amplitude suppression derived from the paper EEG were compared against computer-rated measures of seizure duration, seizure energy index, mean ictal amplitude, and postictal suppression. Our results confirm previous findings of high correlations between computer and visual determinations of seizure duration. Significant differences were found for computer-derived postictal suppression, seizure energy index and mean ictal amplitude for different levels of the visual rating scales. Our results provide preliminary support for the concurrent validity of these measures.

Variation of ictal electroencephalographic regularity with low-, moderate-, and high-dose stimuli during right unilateral electroconvulsive therapy.

BACKGROUND: Previous work has demonstrated changes in electroencephalographic (EEG) ictal morphology during electroconvulsive therapy (ECT) as stimulus intensity is increased from barely suprathreshold to moderately suprathreshold. Our study reports on the reactivity of seizure regularity ratings in 11 subjects receiving right unilateral (RUL) ECT as the stimulus is varied over a wider range of intensities from low to medium, then high dose. METHODS: The stimulus intensity of all 11 subjects was first increased from barely suprathreshold to moderately suprathreshold, and then randomized to either stay at a moderately suprathreshold dose or increase to a high dose. The regularity of the EEG ictal discharge was visually measured on a seven-point scale. RESULTS: We found that seizure regularity increases as the stimulus intensity moves from the barely suprathreshold to the moderately suprathreshold dosage, but did not increase further when the stimulus increased to a high dose. CONCLUSIONS: These results suggest that EEG regularity is unlikely to distinguish moderately suprathreshold from markedly suprathreshold stimuli during RUL ECT.

Mental health services for Alzheimer's disease. Current trends in reimbursement and public policy, and the future under managed care.

Behavioral or psychiatric symptoms in Alzheimer's disease are strongly related to the use of health care services and result in a significant emotional and financial burden for families. This paper is an overview of major trends in the organization and funding of mental health services for people with Alzheimer's disease, emphasizing specific public policy and reimbursement initiatives that have affected acute and long-term care. Recent trends reflecting increased federal scrutiny of Medicare-reimbursed services and the current and future challenges in providing mental health services to people with Alzheimer's disease within managed care and capitated health plans are also addressed.

An international comparison of physicians' judgments of outcome rates of cardiac procedures and attitudes toward risk, uncertainty, justifiability, and regret.

OBJECTIVE: Compare U.K. and U.S. physicians' judgments of population probabilities of important outcomes of invasive cardiac procedures; and values held by them about risk, uncertainty, regret, and justifiability relevant to utilization of cardiac treatments. DESIGN: Cross-sectional study. SETTING: University hospital and VA medical center in the United States; two teaching hospitals in the United Kingdom. PARTICIPANTS: 171 housestaff and attendings at U.S. teaching hospitals; 51 physician trainees and consultants at U.K. hospitals. MEASURES: Judgments of probabilities of severe complications and deaths due to Swan-Ganz catheterization, cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG); judgments of malpractice risks for case vignettes; Nightingale's risk-aversion instrument; Gerrity's reaction-to-uncertainty instrument; questions about need to justify decisions; responses to case vignettes regarding regret. RESULTS: The U.S. physicians judged rates of two bad outcomes of cardiac procedures (complications due to cardiac catheterization; death due to CABG) to be significantly higher (p < or = 0.01) than did the U.K. physicians (U.S. medians, 5 and 3.5, respectively; U.K. medians 3 and 2). The median ratio of (risk of malpractice suit I error of omission)/(risk of suit I error of commission) judged by U.K. physicians, 3, was significantly (p=0.0006) higher than that judged by U.S. physicians, 1.5. The U.K. physicians were less often risk-seeking in the context of possible losses than the U.S. physicians (odds ratio for practicing in the U.K. as a predictor of risk seeking 0.3, p=0.003). The U.K. physicians had significantly more discomfort with uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (U.K. median 48, U.S. 42, p=0.0001) and the reluctance-to-disclose-uncertainty scale (U.K. 40, U.S. 37, p < 0.0001) of the Gerrity instrument. There was no clear international difference in perceived need to justify decisions, or in regret. CONCLUSIONS: The results were not clearly consistent with the uncertainty hypothesis that international practice variation is due to differences in judged rates of outcomes of therapy or with the imperfect-agency hypothesis that practice variation is due to differences in physicians' personal values. The causes and implications of practice variations remain unclear.

Managed Medicare: an overview for the primary care physician.

Medicare is looking to managed care to help solve its financial burden. Because managed care plans offer a number of advantages for Medicare enrollees, the number of plans and of enrollees are increasing dramatically. With some exceptions, the Medicare population appears to do as well or better in HMOs as in fee-for-service care, despite differences in utilization of services. For the primary care physician, the key to success in managed Medicare is finding and aggressively managing your frail or near frail patients. Basic tools for survival are the use of prevention strategies, screening of enrollees and targeting for needed services, geriatric assessment, use of alternate care settings to avoid or limit costly hospital care, and monitoring of medication use for compliance and adverse reactions.

Phototherapy for patients with Alzheimer disease with disturbed sleep patterns: results of a community-based pilot study.

We examined the entraining effects of phototherapy delivered by light visors on disturbed sleep patterns of community-dwelling research subjects with Alzheimer disease (AD). The pilot project used a single subject design and activity monitoring as the primary outcome measures. The protocol consisted of a 5-day baseline monitoring period, followed by 10 consecutive days of phototherapy (2,000 lux of full spectrum bright light) delivered by light visors for 2 hours each morning; this was followed by an additional 14 days of activity monitoring. Cosinor analyses found no consistent changes in acrophase, mesor, or amplitude. Observed changes in acrophase were consistent with phase advancement of the rest-activity cycle and consistent with the biological intervention. Changes in the number of nighttime awakenings were not found. One subject had a significant increase in total sleep time, whereas another had a significant decrease in total sleep time. Failure to find a consistent biological effect of light on AD subjects may be secondary to: (1) insufficient duration of light exposure; (2) timing of light administration (given at a time when circadian rhythm is refractory to the effects of light); (3) advanced stages of AD making the Y circadian pacemaker in the suprachiasmatic nucleus of the hypothalamus insensitive to the biological effects of light; and (4) inadequacy of light visors as a means of providing light.