Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: Homelessness is a major public health problem among persons with severe mental illness (SMI). Cost-effective programmes that address this problem are needed. AIMS: To evaluate the cost-effectiveness of an assertive community treatment (ACT) programme for these persons in Baltimore, Maryland. METHODS: A total of 152 homeless persons with SMI were randomly allocated to either ACT or usual services. Direct treatment costs and effectiveness, represented by days of stable housing, were assessed. RESULTS: Compared with usual care, ACT costs were significantly lower for mental health in-patient days and mental health emergency room care, and significantly higher for mental health out-patient visits and treatment for substance misuse. ACT patients spent 31% more days in stable housing than those receiving usual care. ACT and usual services incurred $242 and $415 respectively in direct treatment costs per day of stable housing, an efficiency ratio of 0.58 in favour of ACT. Patterns of care and costs varied according to race. CONCLUSION: ACT provides a cost-effective approach to reducing homelessness among persons with severe and persistent mental illnesses.

The relationship between health status and blood pressure in urban African Americans.

African Americans have higher rates of hypertension and poorer health status than their white counterparts. This study assessed the relationship between health status, cardiovascular risk factors, and measured blood pressure. Free blood pressure screenings were performed at businesses and organizations located in west Baltimore. All individuals with cardiovascular risk factors were offered health education. Also, participants with a measured blood pressure of > or = 140/90 mm Hg were referred for free medical treatment. Participants completed a questionnaire that included demographics, cardiovascular risk factors, the Medical Outcomes Study SF 36, and two tests on cholesterol and heart disease knowledge. A total of 1389 African-American men and women were screened; 20% were found to have high normal blood pressure and 31% had stage 1 hypertension or higher. Those with hypertension reported lower physical functioning and poorer general health than those without high blood pressure. When compared with US normative data, participants reported higher levels in vitality and physical and emotional role functioning, more bodily pain, and poorer general health, but they were similar in physical functioning, social functioning, and mental health. Preliminary data suggest that hypertension does have an effect on health function.

A randomized trial of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses. METHODS: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations. RESULTS: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status. CONCLUSIONS: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.

The internal reliability of a General Mattering Scale in homeless men.

199 homeless men were administered the General Mattering Scale to assess their belief that they mattered to others in their community. Analysis indicated that homeless men felt that they were important to others, that others pay attention to them, that they would be missed by others if they went away, that people were interested in what they had to say, and that others depended on them. The General Mattering Scale displayed strong internal consistency (Cronbach alpha of 85).

The appropriate role for the state hospital.

This article explores the role of the state hospital in providing long-term care. It is argued that long-term care is an important part of a mental health system, specifically for people with severe mental illness. The state hospital can be made to function more efficiently and also provide needed long-term care.

Psychiatric hospital care and changes in insurance coverage strategies: a national study.

The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment.

Effects of homelessness on the quality of life of persons with severe mental illness.

OBJECTIVE: This study assessed the relationship between homelessness and specific quality-of-life problems for persons with severe and persistent mental illness. METHODS: The objective and subjective quality of life of 106 homeless persons with severe mental illness who lived on the streets or in shelters in Baltimore was compared with that of 146 domiciled persons with severe mental illness who lived in the community. RESULTS: Objective and subjective quality of life of the homeless subjects was clearly worse than that of the domiciled group in the areas of living situation, family and social relations, employment, daily activities, and legal and safety problems. Homeless subjects were also less likely to have federal disability entitlements. CONCLUSIONS: Poorer quality of life is associated with homelessness among persons with severe mental illness. Their quality of life may be improved by efforts to increase their access to disability entitlements and treatment services and to help them develop supportive social networks.

Knowledge of blood cholesterol reduction in community residents.

This study examined the cholesterol knowledge of inner-city community residents, who are representative of individuals in lower socio-economic groups. "Cholesterol Pursuit," a 10-item cholesterol knowledge test distributed by the National Heart, Lung, and Blood Institute, was administered to 316 residents in eight local grocery stores. The average percentage of correct answers was 65.8%. Community residents in a large, urban city were fairly knowledgeable about blood cholesterol reduction, but there were misconceptions concerning the importance of eggs, fish oil, and olive oil, and with foods marked "no cholesterol." White community residents appeared to be slightly better informed about reducing blood cholesterol. Identification of misperceptions concerning cholesterol will guide future education programs for these specific communities.

Modifying the PACT model to serve homeless persons with severe mental illness.

The success of the Program for Assertive Community Treatment (PACT) has led to its replication with different client populations, especially those who are underserved by the traditional treatment system. This paper describes a program in Baltimore that has adapted the PACT model to serve homeless persons with severe mental illness. Although the essential ingredients and philosophy of the original model were maintained, the original team approach has been modified by the use of "miniteams." All staff share knowledge of all program clients through formal mechanisms such as daily meetings; however, each client is assigned to a miniteam composed of a clinical case manager, a psychiatrist, and a consumer advocate. Another deviation from the PACT model is that services can be time limited. The authors describe four phases of treatment and problems, including interventions characteristic of each phase.

The failure of the diversion process: the impact of transferring of patients to state hospitals.

The diversion of people with severe mental illness into the private sector is examined. The purpose of the diversion system is to reduce the number of admissions to the state hospitals by diverting patients into the private hospitals, which may offer more diverse treatment to these patients. Insurance is highlighted as an important factor in diverting patients from state hospitals. When the diversion system fails and the patient is transferred from the private sector to the state hospitals, continuity of care is disrupted. The failure of the diversion is more costly not only to the patient but to the federal and state governments as well. Policy issues such as cost to the mental health system and continuity of care are discussed.

Family medicine residents' knowledge and attitudes about drug-nutrient interactions.

OBJECTIVE: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that health professionals recognize the importance of drug-nutrient interactions and educate patients to prevent adverse effects. Drug-nutrient interactions are an important issue in medical practice, but it is not clear how or if physicians are trained in this issue. METHODS: This investigation was a needs assessment that examined attitudes and knowledge about drug-nutrient interactions that was examined in a national sample of 834 family medicine residents in 56 residency programs. RESULTS: Most reported they had little or no formal training in drug-nutrient interactions in medical school (83%) or residency (80%). However, 79% believed it was the physician's responsibility to inform patients about drug-nutrient interactions, although many thought pharmacists (75%) and dietitians (66%) share this responsibility. Overall, residents correctly answered 61% +/- 19 of fourteen drug-nutrient interaction knowledge items. There was a slight increase in drug-nutrient knowledge as year of residency increased. CONCLUSIONS: Physicians' knowledge of drug-nutrient interactions may be improved by including nutrition education in the topics taught by physicians, nutritionists, and pharmacists using several educational strategies. Nutrition educators in particular can play a role in curriculum development about drug-nutrient interactions by developing, refining, and evaluating materials and educational tools. Nutrition educators need to provide this information in academic settings for the training of all health professionals as well as in patient education settings such as hospitals and public health clinics.

Trends in the inpatient care of persons with schizophrenia.

This report analyzes nationally representative data to examine inpatient services provided to persons with schizophrenia. The data are for patients admitted to general hospitals, private psychiatric hospitals, and State and county mental hospitals between 1970 and 1986 (weighted n = 860,637). The proportion of admissions diagnosed as having schizophrenia decreased from 21 percent in 1970 to 16 percent in 1986; this proportion decreased in public general hospitals and increased in private general hospitals. The rate of admissions for schizophrenia decreased in public general hospitals and State and county mental hospitals and increased in private general hospitals. The overall admissions rate decreased for whites with schizophrenia and increased for African-Americans, owing entirely to increased admissions of African-American males. Private general hospitals and State and county mental hospitals relied less over time on private insurance; the use of Medicare increased in both public and private general hospitals; and Medicaid use increased in private general hospitals. Further research on services for this population is necessary as a baseline for health care reform.

Changing characteristics of schizophrenic patients admitted to state hospitals.

OBJECTIVE: Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period. METHODS: Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health. RESULTS: Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients. CONCLUSIONS: Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.

Attitudes of graduating seniors at one medical school toward family practice.

BACKGROUND AND OBJECTIVES: Senior medical students' interest in family practice as a career choice has declined in recent years. METHODS: A questionnaire about attitudes toward family practice was mailed to the 1990 graduating class at the University of Maryland (N = 143), and 84 completed questionnaires were returned (59% response rate). RESULTS: Seniors believed that family practice was challenging (89%) and had intellectual content (integrity) comparable to other specialties (81%). Furthermore, students believed that family physicians provided comprehensive care (88%), were not replaceable by other health professionals (86%), and were able to keep abreast with technological medical advances (52%). However, only 4% of the graduating seniors selected family practice as a career. Most students believed that family practice lacked prestige (82%), and about one half (55%) believed that it was too broad in scope. CONCLUSIONS: Lack of prestige, stressful life-style, difficulty in mastering medical knowledge, and poor potential income were the main reasons given by students for not selecting family practice.

Patterns of interrelations among health-promotion behaviors.

We examined the interrelationships among 36 health behaviors for men and 38 for women in a telephone survey of a national sample of 3,025 adults. Wide variations existed in the frequency of respondents engaging in healthy practices, ranging from 9% to 96%. Men practiced an average of 17, and women 19, healthy behaviors. Correlations between health behaviors were weak, with an absolute value averaging r = .07, ranging from r = .00 to r = .71. Factor analysis revealed 10 underlying dimensions among the behaviors, which we interpreted for men as: (1) health care use, (2) exercise and recreation activity, (3) alcohol use, (4) smoking, (5) physical activity, (6) dental care, (7) nutrition, (8) sleep, (9) beverage use, and (10) breakfast. Women had the same 10 factors as men, except for a women's health screening factor instead of a beverage use factor. These findings suggest that engaging in one health behavior is not necessarily associated with practicing others, and that public health and individual counseling efforts to encourage healthy behaviors should be multifaceted and behavior-specific.

Reliability of Budner's intolerance of ambiguity scale in medical students.

Intolerance of ambiguity is the perception of ambiguous situations as threatening. It has often been measured using Budner's 1962 intolerance of ambiguity scale in studies of medical students and physicians. To examine the test-retest reliability of the scale among that population, we administered it to all 171 entering medical students at one medical school immediately prior to beginning classes and readministered it to them six to nine weeks later with an 81% follow-up rate. The Pearson correlation between the first and second administrations was .64, showing moderate reliability during this stressful period in medical socialization. The internal reliability of the scale remained constant; the alpha was .64 at the first administration and .63 at follow-up. These data indicate moderate reliability of Budner's intolerance of ambiguity scale when respondents are medical students.

Prevalence and characteristics of nursing home-acquired infections in the aged.

OBJECTIVES: This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out. METHODS: The records of 4,259 patients in a stratified random sample of 53 Maryland nursing homes were reviewed for diagnostic procedures, medical, functional, and behavioral status. Infections were identified by signs, symptoms, and laboratory findings. RESULTS: Study patients were characteristic of aged patients in US nursing homes. The prevalence of infections actually acquired in the nursing home (80% of all infections) was 4.4%. Multivariate analysis revealed that skin infections (35% of nursing home-acquired infections) were associated with skin ulcers and inversely with urine incontinence. Fevers of uncertain source (13%) were associated with bladder catheters. Symptomatic urinary infections (12%) and lower respiratory infections (12%) were associated with bedfast status, and the latter with tracheostomy and lung disease. Skin ulcers, urethral catheters, and bedfast status were markers for nursing home-acquired infection. The prevalence of infection in patients with all three markers was 32%; in patients with none, 2%. Fewer than a quarter of the four most common nursing home-acquired infections received an evaluation which met minimal diagnostic criteria established by a panel of infectious disease specialists and geriatricians. Patients with dementia, those in large homes (greater than 150 beds), and those in urban homes were less likely to be evaluated in a manner meeting these criteria. CONCLUSIONS: Use of three characteristics (ie skin ulcers, urethral catheters, bedfast status) to identify patients at risk for nursing home-acquired infections may allow targeted infection surveillance and prevention programs. In addition, nursing home-acquired infections are not evaluated uniformly across patients and facilities, suggesting the need to establish, through further study, guidelines for such evaluations.

Attitudes toward condom use and AIDS among patients from an urban family practice center.

As part of an effort to better educate patients about using condoms, a survey was done to assess the sexual practices, attitudes toward acquired immunodeficiency syndrome (AIDS) and condom use by patients who visit an urban family practice center. A self-administered questionnaire was given to 126 patients of whom the majority were black and single. Seventeen percent indicated they had sex with more than one person in the 3 months before the survey. Within the last 5 years, 10% had sex with an intravenous drug abuser, and 6% with someone of the same sex. Fifty percent believed that condoms decrease sexual pleasure for men and 31% thought condoms made sex inconvenient. Twenty-seven percent of those surveyed believed that a man's penis may be too large for a condom and 18% believed that uncircumcised men could not use condoms. Forty-five percent believed they should be screened for human immune deficiency virus exposure. The results highlight attitudes and beliefs that may function as barriers to condom use and should be addressed when encouraging condom use with this population.

PIP: Attitudes toward condom use and AIDS were examined in a study of urban family planning clinic clients in Baltimore, Maryland. 126 respondents (71% response rate) out of 12,000 encounters per year participated in the 51-term questionnaire. Clinic clients are predominantly black, female, and young, although 20% are males. Respondents' mean age was 30 and most were black, never-married females. 89% engaged in sexual activity within the prior 3 months of the survey. 73% had 1 partner, 9% had 2 partners, 3% had 4 partners, and 11% had no partners. The average occasion of intercourse was 6.4 times/week. 14% used condoms all the time. 25% used at least 1 drug prior to intercourse. 10% had had intercourse with an iv drug user in the past 5 years. 1% had sex with an acknowledged AIDS patient. 23% knew 1 individual with AIDS. Attitudinal results indicated a wide variety of opinions on condoms and AIDS. 91% considered carrying condoms all right, 92% insisting on condom use, or 88% refusing sex without a condom; women found these statements more acceptable than men. In spite of beliefs, 50% or less of respondents indicated partner use of condoms. 52% of those finding decreased sexual pleasure for men and 56% finding decreased sexual pleasure for women had never used condoms. 75% expressed concern about contracting AIDS. 25% had been screened, and 40% believed they should be screened, of which 39% had never used a condom. 78% believed that condoms prevent AIDS, while 87% believed condoms prevent gonorrhea or 86% syphilis. 27% believed that a penis could be too large for a condom, and 18% believed condoms could not be used by circumcised men. 14% believed a condom could be used on a flaccid penis. It is concluded that use and beliefs about condoms do not coincide. Barriers to use were identified as cost of condoms (38% of men believed condoms were expensive) and embarrassment (26% of women were embarrassed to by condoms). Decrease in sexual pleasure was another deterrent to use. Misconceptions need to be confronted; i.e., the belief that religious people do not use condoms or only homosexuals get AIDS. It is recommended that the cultural basis of these attitudes be determined or the source of misconceptions. Educational strategies for racially distinct groups by sex need to be designed, implemented, and evaluated.

Intolerance of ambiguity among family practice residents.

The art of clinical medicine involves learning to deal with varying levels of ambiguity and uncertainty. Tolerance of ambiguity was examined by giving Budner's Intolerance of Ambiguity Scale to a sample of 37 family practice residents from a university hospital residency and 22 from a community hospital residency. Residents in both the community and university programs had similar scores. No differences existed between men and women. Compared to studies of medical students, first-year family practice residents were slightly more intolerant of ambiguity. However, intolerance of ambiguity was lower among third-year residents, suggesting that as training advances, residents may become more tolerant of ambiguity. The residency training process may lead to a reduction in intolerance of ambiguity, which produces physicians who can deal with the ambiguity and uncertainty of clinical practice.