Patient satisfaction with an injection device for multiple sclerosis treatment.

OBJECTIVES: To develop a measure of treatment satisfaction assessing attributes specific to injected interferon-beta-1a (IFN-beta-1a) for multiple sclerosis (MS), and to test pain and instrument sensitivity to change among patients changing injection devices. MATERIALS AND METHODS: The MS Treatment Concerns Questionnaire (MSTCQ) was developed and tested with pain assessments before and 3 months after patients changed devices from Rebiject to Rebiject II. RESULTS: The MSTCQ was organized with two domains: Injection System Satisfaction and Side Effects (three subscales: Injection Site Reactions, Global Satisfaction, and Flu-Like Symptoms). Significant improvements (P = 0.002 to P < 0.001) occurred with the new injection device in all MSTCQ subscales (except Flu-Like Symptoms), and all pain measures (P < 0.0001). Clinically meaningful improvement was demonstrated in all scales, except Flu-Like Symptoms, by effect sizes (0.23-0.59). CONCLUSIONS: These statistically significant and clinically meaningful improvements in MSTCQ and pain measures show the value of technologically advanced devices in domains of concern to patients.

The relationship between treatment access and spending in a managed behavioral health organization.

OBJECTIVE: This study replicated an earlier study that showed a linear relationship between level of treatment access and behavioral health spending. The study reported here examined whether this relationship varies by important characteristics of behavioral health plans. METHODS: Access rates and total spending over a five- to seven-year period were computed for 30 behavioral health plans. Regression analysis was used to estimate the relationship between access and spending and to examine whether it varied with the characteristics of benefit plans. RESULTS: A linear relationship was found between level of treatment access and behavioral health spending. However, the relationship closely paralleled that found in the earlier study only for benefit plans with an employee assistance program linked to the managed behavioral health organization and for plans that do not allow the use of out-of-network providers. CONCLUSIONS: The results of this study replicate those of the earlier study in showing a linear relationship between access and spending, but they suggest that the magnitude of this relationship may vary according to key plan characteristics.

The impact of prior authorization on outpatient utilization in managed behavioral health plans.

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.

Does managing behavioral health care services increase the cost of providing medical care?

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting--by denying care or impeding access to care--and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.

The association between body mass and health care expenditures.

With several studies estimating the health care costs attributable to obesity-related medical conditions, the economic consequences of being overweight are beginning to come into focus. The present study complements this growing body of literature by directly estimating health care costs across a broad range of body mass index values. Data were obtained from the 1987 National Medical Expenditure Survey (NMES) public use data tapes and retrospective analyses conducted on NMES Household Survey data only. The analyses included a total of 16,217 individuals between the ages of 18 and 65. Four classes of health care utilization and expenditures were derived using the NMES data: (1) use of any health care service and total health care expenditures, (2) use of inpatient services and inpatient expenditures, (3) use of outpatient services and outpatient expenditures, and (4) use of prescription medication and medication expenditures. Estimates based on our findings suggested strong relationships between body mass and the likelihood of using health care services and between body mass and average annual health care expenditures for both men and women. Increased body mass was associated with increased expenditures. However, this association was greater among males than among females and did not hold for individuals in the lowest body mass category. Ideal body mass was associated with 6.3% to 36.1% lower annual health care expenditures among females and 3.6% to 18.2% lower health care expenditures among males. The results of this set of analyses suggest that health care expenditures increase as weight deviates from the ideal-that is, health care expenditures among both underweight and overweight individuals in the United States were increased in relation to ideal weight. Separate analyses including weight-related diseases such as diabetes and hypertension indicated that body mass increased health care expenditures largely by increasing the risk for these costly chronic medical conditions.

An instrument for measurement of outcomes of care for schizophrenia. Issues in development and implementation.

To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrument for monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panel's deliberations and determined the module's content and characteristics are described. Initial field testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Health's Plan for Research on the Severely Mentally Ill. As such, it is a promising tool for effectiveness research in schizophrenia.

Awareness of illness in schizophrenia and outpatient treatment adherence.

We present a brief measure of awareness of illness in schizophrenia and test whether awareness is related to perceived need for and adherence to outpatient psychiatric treatment. A prospective design assessed treatment adherence, awareness of the signs and symptoms of schizophrenia, symptoms, neurocognitive status, and substance abuse at baseline and 6-month follow-up in 89 persons with schizophrenia. Results indicate that persons with greater awareness perceived greater need for outpatient treatment and evidenced better adherence to outpatient treatment when adherence and awareness were measured concurrently. Awareness was not related to adherence at 6-month follow-up. In addition, neurocognitive impairment was associated with lower overall adherence to treatment when reported by collaterals at baseline and 6-month follow-up. Neurocognitive impairment was, however, associated with higher self-reported adherence to medication, which suggests that neurocognitive status may bias adherence reporting in persons with schizophrenia.

Substance abuse, community service use, and symptom severity of urban and rural residents with schizoprhenia.

OBJECTIVE: This study examined the relationships of substance abuse, use of community-based services, and symptom severity among rural and urban residents with schizophrenia in the six months after discharge from short-term inpatient care. METHODS: At baseline and six-month follow-up, symptom severity of 139 subjects was assessed using the Brief Psychiatric Rating Scale (BPRS), and substance abuse status was determined using the Structured Clinical Interview for DSM-III-R (SCID). Subjects' reports of mental health service use were confirmed by record review. RESULTS: Although, on average, BPRS scores indicated symptom improvement between baseline and follow-up, symptoms worsened for 27 percent of subjects. Multivariate analysis, adjusted for baseline symptom severity, indicated poorer outcomes for rural residents, substance abusers, and subjects who did not use community services. Symptoms of rural substance abusers who used no community services were worse at follow-up than those of any other subgroup. Nearly half of all subjects had less than monthly contact with community services. The greater likelihood of symptom worsening among rural residents was attributed to their less frequent use of community services. CONCLUSIONS: The findings reinforce the importance of ensuring involvement in community-based services for individuals with comorbid schizophrenia and substance use disorders. Promotion of service use by persons with a dual diagnosis may be particularly critical to the well-being of rural residents with schizophrenia.

Medication noncompliance and substance abuse among patients with schizophrenia.

OBJECTIVE: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. METHODS: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. RESULTS: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. CONCLUSIONS: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Symptom heterogeneity in comorbid alcohol disorder.

The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder.

Treatment costs and use of community mental health services for schizophrenia by age cohorts.

OBJECTIVE: Research on schizophrenia has tended to ignore patterns and costs of mental health service use in late life. The present study examined the types of mental health services used and their costs for several age-defined cohorts in a large community mental health system. METHOD: The data covered all users of the mental health system included in the San Diego county billing information system in fiscal years 1986 and 1990. Community mental health service use and codes were modeled as a function of patient demographic characteristics, diagnosis, and age. The patients were grouped into the following age categories: 18-29, 30-44, 45-54, 55-64, 65-74, and > or = 75 years of age. RESULTS: The total costs for schizophrenia were higher than those for other psychiatric disorders, and they were also age dependent. In both fiscal years, the costs of schizophrenia were higher for the youngest and oldest cohorts than for the patients in the 30-65-year range. CONCLUSIONS: The economic burden of late-life schizophrenia to the public mental health system is at least as high as that of schizophrenia in younger adults.

Managed care in the public mental health system.

The movement towards managed care in the public mental health system has surpassed efforts to develop a systematic literature concerning its theory, practice, and outcome. In particular little has been written about potential challenges and difficulties in translating managed care systems from their origins in the private sector to the delivery of public sector mental health services. This paper provides an overview of managed care definitions, organizational arrangements, administrative techniques, and roles and responsibilities using a theoretical framework adopted from economics referred to as principal-agent theory. Consistent with this theory, we assert that the primary function of the managed care organization is to act as agent for the payor and to manage the relationships between payors, providers, and consumers. From this perspective, managed care organizations in the public mental health system will be forced to manage an extremely complex set of relationships between multiple government payors, communities, mental health providers, and consumers. In each relationship, we have identified many challenges for managed care including the complexity of public financing, the vulnerable nature of the population served, and the importance of synchronization between managed care performance and community expectations for the public mental health system. In our view, policy regarding the role of managed care in the public mental health system must evolve from an understanding of the dynamics of government-community-provider-consumer "agency relationships".

Comorbid substance use disorder: prevalence, patterns of use, and course.

Research on the prevalence, patterns, and course of substance use disorders in severe mental illness gives key insights into the complex interaction of substance use and mental disorder. Understanding the literature on comorbidity has implications for the design of clinical services and for the direction of future research in the field.

The California Adult Performance Outcome Survey: preliminary evidence on reliability and validity.

Recent legislation in California mandated the development of an outcome measure suitable for measuring changes in quality of life associated with treatment in the public mental health system. The measure, known as the California Adult Performance Outcome Survey (CAPOS), relies on clinician and client reports of objective and subjective indicators of quality of life. The present study sought to determine whether the clinician-administered CAPOS would agree with that administered by trained research assistants, and whether the CAPOS would agree with an established quality of life measure. A sample of sixty-four severely mentally ill subjects were assessed by their regular mental health provider using the CAPOS. One week later they were assessed by a trained research assistant using the CAPOS and Lehman's Quality of Life Interview (QOLI). For most outcome domains, the CAPOS exhibited moderate to excellent agreement across occasions and raters. Correlations with the QOLI indicated a good degree of overlap among corresponding domains. Outcome measurement procedures for routine use in clinical settings are in their infancy. The CAPOS appears promising in this role because of its brevity, ease of administration, and adequate interrater reliability. The CAPOS affords state and local mental health authorities with an efficient means of tracking key quality of life indicators within the public mental health system.

A longitudinal study of substance use and community violence in schizophrenia.

The authors report the findings of a longitudinal study testing the hypothesis that substance use leads to subsequent violence in the community. Subjects were 103 patients with a Structured Clinical Interview for DSM-III-R diagnosis of schizophrenia or schizoaffective disorder who were seen in an outpatient clinic for the treatment of schizophrenia. Data on substance use and violent behavior were collected by review of medical records. Results indicated that use of drugs and alcohol was associated with increased odds of concurrent and future violent behavior when compared with persons with schizophrenia and no substance use. Odds of violence were particularly elevated for individuals having a pattern of polysubstance use involving illicit substances.

Violent and destructive behavior among the severely mentally ill in rural areas: evidence from Arkansas' community mental health system.

A comparison of rates of violence among admissions to the Arkansas State Hospital system between urban and rural areas tested the hypothesis that thresholds for admission to the hospital were greater in rural than in urban areas. Data on violent and destructive behavior were recorded from the medical records of 609 patients. Logistic regression was used to model the presence or absence of violent behavior in urban and rural admissions controlling for selected demographic and clinical characteristics. Results indicated that rural patients showed increased likelihood of violent and destructive behavior prior to admission supporting the hypothesis that barriers to mental health services in rural areas may be creating differential thresholds of service access and utilization. The increased rate of violence was particularly evident in those using substances prior to admission in rural areas suggesting that community management of the violent, substance abusing patient may be particularly difficult for rural areas.

Remission and relapse of substance use disorders in schizophrenia. Results from a one-year prospective study.

Recent studies of the effectiveness of specialized programs that treat substance use disorders in schizophrenia have obtained promising results but have not involved control groups. Interpretation of these apparently positive results is problematic because remission and relapse rates of substance use disorders have not been reported in this population. The present study reports 1-year rates of substance abuse and dependence remission and relapse in a sample of schizophrenics taken from the Epidemiologic Catchment Area study. Results indicated that the prevalence of substance use disorders in schizophrenia remained constant over the year primarily because rates of remission were balanced by rates of relapse. Individuals who developed abuse or dependence over the year were younger, male, and showed increases in depression and risk for hospitalization over the year. Individuals who remitted abuse or dependence were older, female, and showed decreases in depression over the year. Dual diagnosis treatment programs have recently reported higher rates of remission than were evidenced in this sample, thus providing preliminary support for the effectiveness of these treatments.