Cognitive slowing in Parkinson's disease resolves after practice.

OBJECTIVE: To assess the effect of dopaminergic repletion on working memory in Parkinson's disease. METHODS: The role of dopaminergic state on working memory in patients with Parkinson's disease was determined using the Sternberg item recognition paradigm, a continuous performance task that dissociates the motor and cognitive components of response time. Ten patients with Parkinson's disease were tested in an "on" state (on dopaminergic drug treatment) and a practical "off" state in two sessions held one week apart in counterbalanced order; 10 controls matched for age and education were studied at the same time points. RESULTS: Patients with Parkinson's disease showed impaired working memory, independent of motor slowing. During session 1, the performance of the patients was worse than the controls, regardless of dopaminergic state. The patients showed a significant improvement in the cognitive component of task performance during the second session, such that they no longer differed from the controls. The performance of the control subjects remained stable over the two sessions. CONCLUSIONS: Working memory performance of patients with Parkinson's disease did not change in association with dopaminergic state; rather, the performance improved over time. The pattern of improvement over time suggests a delay in proceduralising the task, similar to the deficits shown by such patients in procedural learning of other tasks.

Lessons from the unexpected: the importance of data infrastructure, conceptual models, and serendipity in health services research.

In examining the importance of data systems, conceptual models, and serendipity in understanding health services, the case is made for a vigorous and responsive data infrastructure and more emphasis on conceptual development. Particularly important is the development of data systems that can keep pace with changes in health care organization and patterns of care. Three examples--from managed care, deinstitutionalization, and physician remuneration--demonstrate the need to empirically examine seemingly obvious assumptions about health patterns and trends, and the lessons to be learned when assumptions are proved incorrect. Major future challenges include incorporating patient preferences into outcomes research, meaningful communication about treatment options and health plan choices, and understanding how organizational culture and norms affect decision processes.

The managed care backlash: perceptions and rhetoric in health care policy and the potential for health care reform.

The focus on managed care and the managed care backlash divert attention from more important national health issues, such as insurance coverage and quality of care. The ongoing public debate often does not accurately convey the key issues or the relevant evidence. Important perceptions of reduced encounter time with physicians, limitations on physicians' ability to communicate options to patients, and blocked access to inpatient care, among others, are either incorrect or exaggerated. The public backlash reflects a lack of trust resulting from cost constraints, explicit rationing, and media coverage. Inevitable errors are now readily attributed to managed care practices and organizations. Some procedural consumer protections may help restore the eroding trust and refocus public discussion on more central issues.

Are patients' office visits with physicians getting shorter?

BACKGROUND: Many believe that managed care creates pressure on physicians to increase productivity, see more patients, and spend less time with each patient. METHODS: We used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics and the American Medical Association's Socioeconomic Monitoring System (SMS) to examine the length of office visits with physicians from 1989 through 1998. We assessed the trends for visits covered by a managed-care or other prepaid health plan (prepaid visits) and non-prepaid visits for primary and specialty care, for new and established patients, and for common and serious diagnoses. RESULTS: Between 1989 and 1998 the number of visits to physicians' offices increased significantly from 677 million to 797 million, although the rate of visits per 100 population did not change significantly. The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998. The duration of the visits increased for both prepaid and nonprepaid visits. Nonprepaid visits were consistently longer than prepaid visits, although the gap declined from 1 minute in 1989 to 0.6 minute in 1998. There was an upward trend in the length of visits for both primary and specialty care and for both new and established patients. The average length of visits remained stable or increased for patients with the most common diagnoses and for those with the most serious diagnoses. CONCLUSIONS: Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.

Managed care and the imperative for a new professional ethic.

Physicians complain about the growth of managed care structures and strategies and their effects on treatment autonomy and medical professionalism. Organizational changes and a competitive marketplace make the traditional view less relevant today. New concepts of professionalism are needed that recognize constraints and include patient advocacy within a framework of procedural justice, responsibility for population health, new patient partnerships, and participation in an evidence-based culture. Such changes require more focused efforts in medical education to support the new professionalism.

Concepts of trust among patients with serious illness.

This paper examines conceptions of trust among three groups of respondents diagnosed with either breast cancer, Lyme disease or mental illness. Interviews were carried out using an open-ended interview guide to explore how patients made assessments of trust in their doctors and health care plans. The guide followed a conceptual approach that asked questions about competence, agency/fiduciary responsibility, control, disclosure and confidentiality. Respondents were given ample opportunity to raise other areas of concern. The data were organized using the NUDIST software package for the analysis of non-numerical and unstructured qualitative data. Patients viewed trust as an iterative process and commonly tested their physicians against their knowledge and expectations. Interpersonal competence, involving caring, concern and compassion, was the most common aspect of trust reported, with listening as a central focus. Most patient comments referred to learnable skills and not simply to personality characteristics. Technical competence also received high priority but was often assessed by reputation or interpersonal cues. Patients were much concerned that doctors be their agents and fight for their interests with health care plans. Disclosure and confidentiality were less common concerns; most patients anticipated that doctors would be honest with them and respect their confidences. Patients' responses also appeared to vary by their disease, their socio-demographic characteristics, their involvement with self-help groups, and how their illness conditions unfolded.

Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk.

OBJECTIVE: To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group. DATA SOURCE: The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample. STUDY DESIGN: Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression. PRINCIPAL FINDINGS: The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders. CONCLUSIONS: Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment.

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995.

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.

Predicting medication noncompliance after hospital discharge among patients with schizophrenia.

OBJECTIVE: The study sought to identify predictors of noncompliance with medication in a cohort of patients with schizophrenia after discharge from acute hospitalization. METHODS: Adult psychiatric inpatients with schizophrenia or schizoaffective disorder for whom oral antipsychotics were prescribed (N=213) were evaluated at hospital discharge and three months later to assess medication compliance. Comparisons were made between patients who reported stopping their medications for one week or longer and patients who reported more continuous medication use. RESULTS: Of the 213 patients, about a fifth (19.2 percent) met the criterion for noncompliance. Medication noncompliance was significantly associated with an increased risk of rehospitalization, emergency room visits, homelessness, and symptom exacerbation. Compared with the compliant group, the noncompliant group was significantly more likely to have a history of medication noncompliance, substance abuse or dependence, and difficulty recognizing their own symptoms. Patients who became medication noncompliant were significantly less likely to have formed a good therapeutic alliance during hospitalization as measured by inpatient staff reports and were more likely to have family members who refused to become involved in their treatment. CONCLUSIONS: Patients with schizophrenia at high risk for medication noncompliance after acute hospitalization are characterized by a history of medication noncompliance, recent substance use, difficulty recognizing their own symptoms, a weak alliance with inpatient staff, and family who refuse to become involved in inpatient treatment.

Responses of HMO medical directors to trust building in managed care.

Managed care organizations (MCOs) are facing intense criticism at national, state, and local levels and battling initiatives that would impose stricter regulation. Medical directors of HMOs were surveyed regarding their organizations' strategies of communication, the programs they have instituted to build trust, and their commitment to sponsoring family and patient support groups. The responses obtained from 252 directors indicate that nonprofit and free-standing organizations are more likely than either for-profit HMOs or organizations that are part of a chain to sponsor community activities and programs and to offer family and patient support groups. Staff- and group-model HMOs are more likely than other organizational configurations to initiate many types of "trust programs." The results indicate that more dispersed and "virtual-type" organizations must explore ways to respond meaningfully to community concerns--and to public health, prevention, and health promotion needs as well--while continuing to improve their practice patterns.

Mission unfulfilled: potholes on the road to mental health parity.

Managed care holds the promise of facilitating parity between general medical care and alcohol, drug, and mental health care by reducing expenditures, even while expanding benefits. Limitations in our knowledge of variations in needs and treatment standards for substance use and psychiatric illnesses make such disorders an easy target for management. Costs for behavioral health care services have been reduced at a faster pace than has been the case for general medical care costs. The most severely ill face the potential burdens of managed care as access and intensity of care become more uniform across patient populations.

Prediction of homelessness within three months of discharge among inpatients with schizophrenia.

OBJECTIVE: The authors' goal was to identify factors that place inpatients with schizophrenia at risk of becoming homeless after hospital discharge. METHODS: Patients with schizophrenia or schizoaffective disorder (N=263) were assessed at discharge from general hospitals in New York City and reassessed three months later to evaluate whether they had become homeless. Sociodemographic and clinical characteristics associated with homelessness were identified using likelihood ratio chi square analysis and logistic regression. RESULTS: Twenty patients (7.6 percent) reported an episode of homelessness during the follow-up period. Patients who had a drug use disorder at hospital discharge were significantly more likely to report becoming homeless than those without a drug use disorder. Patients with a total score above 40 on the Brief Psychiatric Rating Scale (BPRS) at hospital discharge were more likely to report becoming homeless than patients with lower scores, as were those with Global Assessment Scores less than 43. Twelve of 30 patients with a drug use disorder, a BPRS score above 40, and a GAS score less than 43 at hospital discharge reported becoming homeless. CONCLUSIONS: The combination of a drug use disorder, persistent psychiatric symptoms, and impaired global functioning at the time of hospital discharge poses a substantial short-term risk of homelessness among patients with schizophrenia. Patients who fit this profile may be candidates for community-based programs that are specifically aimed at preventing homelessness among patients with severe mental illness.

Issues in promoting health.

Policymakers in many countries seek to contain health care costs over the long range by promoting health and more effective health behavior. Such efforts can be directed at entire populations, at members of a health plan, at defined risk groups or single individuals at risk. Many health risks are associated with socio-economic status and social inequalities but these are often difficult to address because of social and political conflicts. Health, also, is often a product of culture and other social circumstances. Health may be promoted through non-health interventions or through more targeted health efforts seeking to effect behavior change. Preventive screening is of growing importance but such efforts often out-pace evidence of efficacy or cost-effectiveness. Many opportunities exist to build on new clinician-patient partnerships to make patients better informed and to effect positive health behavior. New technologies, and particularly the internet, offer new ways to promote health and more constructive illness behaviors.

The changing elderly population and future health care needs.

The impending growth of the elderly population requires both fiscal and substantive changes in Medicare and Medicaid that are responsive to cost issues and to changing patterns of need. More emphasis is required on chronic disease management, on meaningful integration between acute and long-term care services, and on improved coordination between Medicare and Medicaid initiatives. This paper reviews various trends, including the growth in managed-care approaches, experience with social health maintenance organizations and Program of All-Inclusive Care for the Elderly demonstrations, and the need for a coherent long-term care policy. Such policies, however, transcend health care and require a broad range of community initiatives.

Assessing clinical predictions of early rehospitalization in schizophrenia.

This study determines patient characteristics that predict early hospital readmission in schizophrenia and evaluates the extent to which inpatient staff accurately predict these readmissions. Adult inpatients with schizophrenia or schizoaffective disorder (N = 262) were evaluated at hospital discharge and 3 months later to assess hospital readmission. At hospital discharge, inpatient staff were asked to identify which patients were likely to be readmitted during this period. Comparisons were made between patients who were or were not readmitted and between readmitted patients who were or were not identified by staff as likely to be readmitted; 24.4% of the sample were readmitted within 3 months of hospital discharge. Early readmission was associated with four or more previous hospitalizations (85.7% vs. 57.7%, p = .004), comorbid substance use disorder (60.3% vs. 35.5%, p = .0006), major depression (40.6% vs. 26.8%, p = .04), absence of a family meeting with inpatient staff (58.2% vs. 41.8%, p = .02), and prescription of a conventional rather than an atypical antipsychotic medication (93.7% vs. 83.8%, p = .045). Twelve of the 63 readmitted patients were correctly predicted by staff to re-hospitalize. Staff tended to overestimate the risk of rehospitalization in patients with a poor therapeutic alliance, low global function, or initial involuntary admission and to underestimate the risk in patients with alcohol use disorders or four or more previous psychiatric hospitalizations. Early rehospitalization is common in schizophrenia and difficult to predict. Greater emphasis on comorbid alcohol use disorders and a history of multiple previous admissions may help clinicians identify patients at greatest risk for early rehospitalization.