Short-term course of drinking in an untreated sample of at-risk drinkers.

OBJECTIVE: We know little about the short-term course of drinking, particularly the stability or instability of at-risk drinking in untreated drinkers. Because few at-risk drinkers obtain help for their drinking, it is important to understand the short-term fluctuations between at-risk drinking and full-fledged alcohol use disorders, as well as remission of at-risk drinking. METHOD: We used four waves of data (each 6 months apart) from a probability community sample of 733 at-risk drinkers in six states in the southern United States to determine variation in abstinence, drinking patterns and alcohol use disorders over a 2-year period. For this analysis, we excluded those who reported receiving services for drinking during the 2-year study period (retrospectively at baseline), leaving a sample size of 664 (444 male); 479 (306 male) completed all four interviews. RESULTS: Although the majority (88%) of the sample was nonabstinent throughout the study, we found significant decreases in average number of drinks per drinking day and recent (past 6 months) alcohol disorders, and an increase in 6-month abstinence. Almost 30% of those with no recent alcohol disorder at baseline (n = 280) later met diagnostic criteria in at least one interview. Of those with a recent alcohol disorder at baseline (n = 199), one third met criteria in at least two subsequent interviews. CONCLUSIONS: There is some evidence for short-term progression from at-risk drinking to alcohol disorder. However, there is stronger evidence for declining problems and a fluctuation in and out of recovery and relapse, which may reflect an effort to maintain controlled drinking. Understanding this short-term course is important for primary and secondary prevention efforts and for screening of at-risk drinking in primary care and in the workplace.

A community study of depression treatment and employment earnings.

OBJECTIVE: Although treatment for major depression has been shown to reduce the costs of lost earnings resulting from lost work days, research has not demonstrated whether the reduction fully offsets the costs of treatment for the disorder. METHODS: A statewide cohort of community residents with recent major depression, dysthymia, or substantial depressive symptoms was recruited and interviewed at baseline and at six-month and 12-month follow-ups. The cost of lost earnings was measured by lost work days multiplied by subjects' wage rates. Cost of treatment for depression was approximated using charges abstracted from provider and insurance records. Net economic cost, defined as the sum of changes in lost earnings and depression treatment costs, was examined in multiple regression analyses. RESULTS: After the analyses controlled for sociodemographic characteristics, baseline severity of depression, and comorbidity, no statistically significant effect of depression treatment on net economic cost was found. This finding suggests that the cost of depression treatment was fully offset by savings from reduction in lost work days. Results from sensitivity analyses in multiple alternative scenarios support the same conclusion. CONCLUSIONS: The finding of a full offset of depression treatment cost is conservative because other benefits, such as reduced pain and suffering and increased productivity while at work, were not included in the analyses. Employers who bear the cost from lost work days should encourage their employees with depressive disorders to seek treatment, even if it means paying for the entire treatment cost. Self-employed individuals with depression also will benefit even if they pay for the treatment costs themselves.

Impact of travel distance on the disposition of patients presenting for emergency psychiatric care.

For veterans presenting for emergency psychiatric care, this research tested the hypothesis that patients with poor geographic accessibility to ambulatory mental health services would be more likely to be hospitalized. Logistic regression results indicated that distant patients (> 60 miles) were 4.8 times more likely (p < .05) to be admitted for acute psychiatric treatment than were proximal patients (< 60 miles), controlling for clinical and demographic case-mix factors. This finding suggests that the Department of Veterans Affairs might be less effective in its effort to substitute intensive outpatient care in place of expensive inpatient treatment for rural veterans with emergent mental health problems.

Do patients with alcohol dependence use more services? A comparative analysis with other chronic disorders.

OBJECTIVE: The primary purpose of this research was to compare the service use of patients diagnosed with alcohol dependence to the service use of patients diagnosed with other chronic illnesses. The secondary purpose was to determine the impact of comorbid alcoholism on the service use of patients with chronic illnesses. METHODS: The sample included 67,878 veterans diagnosed with alcohol dependence, depression, or diabetes who were treated by the Department of Veterans Affairs in 1993. The number of inpatient days and outpatient visits over a 4-year period (1991 to 1995) were compared using regression models to control for differences in casemix. RESULTS: Controlling for casemix, patients treated for alcohol dependence had significantly fewer outpatient visits than patients treated for either depression or diabetes. Patients treated for alcohol dependence also had significantly fewer inpatient days than patients treated for depression, but significantly more inpatient days than patients treated for diabetes. Comorbid alcoholism was prevalent among patients treated for depression and diabetes. Comorbid alcoholism increased the number of inpatient days for patients treated for depression or diabetes and increased the number outpatient visits for patients with depression. However, comorbid alcoholism decreased the number of outpatient visits for patients treated for diabetes. CONCLUSIONS: Results suggest that patients with alcohol use disorders should not be singled out as being more costly to treat than patients with other chronic illnesses. These findings are in stark contrast to those from studies comparing individuals with alcohol use disorders to relatively healthy individuals sampled from at-risk populations.

Earnings changes for depressed individuals treated by mental health specialists.

OBJECTIVE: It is unclear whether the additional benefits of receiving depression treatment from mental health specialists in routine care pays for the additional costs, compared with treatment delivered by general medical providers. This study examines the difference in lost earnings and the difference in treatment costs experienced by depressed individuals treated in these two sectors. METHOD: Representative community residents with depression were recruited and interviewed at baseline and at 6-month and 12-month follow-ups. Lost earnings were measured by lost workdays multiplied by subjects' wage rates. Treatment costs were approximated by charges abstracted from provider and insurance records. RESULTS: After controlling for sociodemographic variables, baseline severity, and baseline comorbidity, the authors found a net mean annual economic savings of $877 associated with depression treatment delivered in the mental health sector compared with the general medical sector. Sensitivity analyses in alternative scenarios indicated similar savings. CONCLUSIONS: Although it is the trend for primary care providers to provide mental health services, these analyses indicate a net economic savings if depression treatment is provided by mental health specialists, probably as a result of patients' greater functional improvement. As gatekeepers, especially in managed care, primary care providers have a unique responsibility to identify and detect patients with mental health problems. In the current structure, however, they may lack the necessary time to provide effective mental health services. Therefore, mental health specialists play a crucial role, with primary care providers' cooperation (i.e., detection, consultation, and referral), in providing the most cost-effective mental health services.

Geographic market areas for psychiatric and medical outpatient treatment.

The research objective was to measure the variation in the size of a facility's market areas across different diagnostic categories. Specifically, the market area radii for outpatient psychiatric services are compared to the radii for outpatient medical services. Data were collected from the outpatient clinics of the Little Rock Veterans Administration Medical Center. Visits were categorized into 100 diagnostic groups. The market radius for each diagnostic group was defined as the 75th quartile of the distribution of distances traveled. All psychiatric diagnostic groups had significantly (p < 0.05) smaller market area radii than the overall sample radius. The average market area radius across psychiatric illnesses was 62.2 miles, which was significantly (p < 0.05) smaller than the average radius across medical illnesses (90.6 miles). Results suggest that rural patients with mental illness may not receive adequate care and that specialized outreach programs may need to be developed to better serve this population.

Relationship between inpatient alcoholism treatment and longitudinal changes in health care utilization.

OBJECTIVE: The purpose of the study was to evaluate changes in health care utilization associated with inpatient alcoholism treatment in alcoholics of low socioeconomic status with different histories of treatment relapse. METHOD: The sample consisted of more than 85,000 male alcoholics using inpatient care in Department of Veterans Affairs medical centers in fiscal year 1987. Five treatment groups were identified to represent a continuum of length and intensity of alcoholism treatment, including formal inpatient alcoholism treatment, short detoxification and hospitalizations for primary diagnoses other than alcoholism. All inpatient and outpatient health services for 3 years before and 3 years after the index hospitalization were examined for differential changes in utilization associated with the five treatment groups after controlling for patient predisposing, enabling and need characteristics. RESULTS: Both total inpatient days and outpatient visits increased significantly for all treatment groups, with the greatest increases occurring in the group completing inpatient alcoholism treatment (both p < .0001). However, use of inpatient medical care decreased and substance abuse inpatient care increased significantly for most groups, with the largest increases in substance abuse care found for the completed treatment group. CONCLUSIONS: In a hospital system that does not deny care on the basis of ability to pay, certain groups of chronic alcoholics who cannot sustain prolonged remission will continue to be heavy utilizers of services. Alcoholism treatment may be associated with higher short-term costs but it remains to be seen whether provision of more focused treatment services is able to achieve longer term better outcomes and, ultimately, lower costs.

Variation among VA hospitals in length of stay for treatment of depression.

OBJECTIVE: The purpose of the study was to determine the degree of interhospital variation in length of stay for patients treated for depressive disorders in Department of Veterans Affairs (VA) medical centers and to identify the number of hospitals with significantly longer or shorter than average lengths of stay (outlier hospitals). METHODS: The sample included 6,374 veterans discharged from acute psychiatric inpatient units at 107 medical centers in 1992 with a primary diagnosis of major depressive disorder or depressive disorder not otherwise specified. To identify statistical outliers, the average length of stay at each medical center was compared with the overall sample mean while controlling for differences in case mix between hospitals. RESULTS: Patients' demographic characteristics, treatment history, and severity of illness all significantly predicted length of stay at the patient level. After case mix factors were controlled for statistically, approximately 29 percent of the medical centers were found to have mean lengths of stay significantly different (p < .01) from the sample mean. Specifically, 15 percent of the medical centers were short-stay outliers, and 14 percent were long-stay outliers. CONCLUSIONS: Despite the fact that the treatment regimen for depression is relatively standardized and all VA medical centers operate under the same administrative model and reimbursement system, a high degree of interhospital variation was found in treatment duration for depression. Results led to the tentative postulation that variations in treatment duration reflect differences in physicians' practice styles. Substantial opportunities may exist for reducing expenditures for the treatment of depression within the VA health care system.

The effects of travel barriers and age on the utilization of alcoholism treatment aftercare.

OBJECTIVE: The objective of this research was to ascertain whether geographical accessibility (in conjunction with other patient characteristics) reduced the probability of participating in alcoholism aftercare treatment. METHODS: A sample of 4,621 United States male veterans discharged with an outpatient appointment from one of 33 Department of Veterans Affairs inpatient Alcohol Dependency Treatment Programs was identified. The outpatient records of each patient were obtained to determine whether aftercare services were utilized following discharge. Binary choice analysis was used to model the decision to enter aftercare treatment as a function of travel distance, age, marital status, ethnicity, severity of illness, and urbanization. RESULTS: Travel barriers significantly reduced aftercare participation, especially for elderly and rural veterans. Both younger and older veterans were less likely to keep their aftercare appointment than middle-aged veterans. Married patients were more likely to utilize outpatient services than unmarried patients. Ethnic status, severity of illness, and urban size all negatively affected the likelihood of appointment attendance. CONCLUSIONS: The results obtained from this analysis can be effectively used to identify which patients are not likely to enter aftercare alcoholism treatment. The discharge plans of patients at risk for appointment noncompliance should be given special attention since aftercare has been shown to improve treatment outcome. Moreover, because alcoholism treatment reduces the utilization of other medical services, promoting continuity of care should help lower the overall costs of providing health care to alcoholic patients.

The relationship between mortality and intensity of inpatient alcoholism treatment.

OBJECTIVES: Previous studies have examined mortality in alcoholics receiving extended inpatient alcoholism treatment, but few have investigated less intense treatment. This study examined mortality within 3 years after discharge from varying intensities of inpatient alcoholism treatment. METHODS: Using the computerized database of the Department of Veterans Affairs, we identified men participating in varying intensities of inpatient alcoholism treatment and followed them for 3 years after discharge. Adjusted mortality rates were computed and survival analysis was performed to assess the risk of death, adjusting for factors that may be related to mortality. RESULTS: The death rate was lower for men who completed extended formal inpatient treatment than for those who began, but did not complete, inpatient treatment or those who underwent short detoxification. Differences among the treatment groups remained after age, race, marital status, and disease severity were controlled. CONCLUSIONS: These results suggest that extended formal inpatient alcoholism treatment is associated with a lower risk of death than less intense forms of inpatient treatment.

Age and ethnicity among hospitalized alcoholics: a nationwide study.

Little is known about the broad-scale demographic characteristics of low income or indigent alcoholics in public hospital systems. The purpose of the study was to examine issues relative to age, race/ethnicity, and marital status for a large group (n = 62,829) of alcoholic men receiving inpatient care in Department of Veterans Affairs (VA) medical centers nationally. Subjects were VA inpatients completing alcoholism treatment (n = 27,562), in brief alcohol detoxification or short intervention (n = 9,322), or hospitalized for primary diagnoses other than alcoholism but with a secondary diagnosis of alcohol dependence syndrome (n = 25,945). Minority alcoholics were significantly younger than Caucasian alcoholics. Hispanic and African-American men, as well as older alcoholics, were significantly less likely to complete treatment or attend detoxification and more likely to be hospitalized for other primary diagnoses. Native Americans, however, were most likely to complete alcoholism treatment. Results suggest that members of some minority groups and elderly alcoholics seek inpatient care for diagnoses other than alcoholism and that, as a result, such individuals may need targeted interventions to encourage them to seek alcohol-specific care.