Predictors of substance abuse treatment retention among women and men in an HMO.

BACKGROUND: Although prior research has examined predictors of treatment retention in public alcohol and drug treatment programs, little is known about factors that influence treatment retention in an insured outpatient population. Because there is growing evidence that the factors which influence treatment retention may differ by gender, we identify sex-specific predictors. METHODS: We recruited all eligible intakes to a health maintenance organization's outpatient alcohol and drug treatment program during a 2-year period and obtained a sample of 317 women and 599 men. The programs, day hospital and traditional outpatient modalities, were abstinence based. We separated our sample by sex and used least squares and logistic regression to identify independent predictors of length of stay and program completion, respectively. RESULTS: One general pattern of predictors of increased retention was shared by women and men in this alcohol and drug treatment program--fewer and less severe drug problems. However, most predictors were sex-specific. Among women, retention was predicted by having higher incomes, belonging to ethnic categories other than African American, being unemployed, being married, and having lower levels of psychiatric severity. Among men, predictors of higher retention included being older, receiving employer suggestions to enter treatment, and having abstinence goals. CONCLUSIONS: These findings highlight the importance of examining aspects of the course of treatment separately by sex. They also suggest treatment factors that may enhance retention among insured populations, including employer referrals, psychiatric services, and drug-related services.

Patterns of diagnoses, comorbidities, and treatment in late-middle-aged and older affective disorder patients: comparison of mental health and medical sectors.

OBJECTIVE: To compare the diagnoses, psychiatric and medical comorbidities, and prior and current treatment received by late-middle-aged and older affective disorder patients in mental health and medical service settings and to identify predictors of these patients' length of inpatient care. DESIGN: Department of Veterans Affairs (VA) nationwide databases are used to examine the prevalence, diagnoses, and inpatient and outpatient treatment received by affective disorder patients in mental health and medical units in Fiscal Year 1990. RESULTS: Compared with late-middle-aged and older index medical patients (n = 11,701), index mental health patients (n = 9039) were more likely to have affective psychoses and major depressive disorder and less likely to have depressive disorder NOS. Almost 60% of affective disorder patients in mental health settings had comorbid psychiatric diagnoses; this was true of 30% of patients in medical settings. Moreover, more than 80% of affective disorder patients in mental health settings had concomitant medical disorders. Affective disorder patients also had very high rates of prior mental health and medical care. Patients who had more severe affective disorders and comorbid psychiatric and medical diagnoses had longer episodes of inpatient care; in contrast, more intensive prior medical and mental health outpatient care was associated with shorter episodes of inpatient care. CONCLUSIONS: The findings highlight affective disorder patients' high rates of comorbidity and intensive use of health care resources, emphasize the value of outpatient care in reducing the amount of subsequent inpatient care, and underscore the need for closer integration of mental health and medical care.

Alcohol consumption, life context, and coping predict mortality among late-middle-aged drinkers and former drinkers.

This study examined mortality risk for individuals in four alcohol consumption categories and identified life context and coping factors that independently predicted mortality among late-middle-aged drinkers and former drinkers (n = 1869). Compared with light drinkers, former drinkers (current abstainers) were at increased mortality risk; moderate drinkers were at decreased risk. Consistent with previous research on older samples, heavy drinkers were not at increased risk. Abstainers' increased risk was reduced in a model that controlled for life context and coping factors. Other independent predictors of mortality included reporting an illness stressor, stressor severity, less participation in activities with friends, greater use of resigned acceptance and alternative rewards coping, and less use of cognitive avoidance and emotional discharge coping. The findings support previous research on the alcohol-mortality relationship among older adults, and highlight the fact that abstainers' life stressors and avoidance coping responses may be more important predictors of their mortality than their abstention.

Program characteristics and readmission among older substance abuse patients: comparisons with middle-aged and younger patients.

Older substance abuse patients were compared to middle-aged and younger patients before, during, and after an index episode of inpatient care in 1 of 88 substance abuse treatment programs. Associations between program characteristics and readmission rates adjusted for key differences in the types of patients in different programs varied by age group. Among older patients, more structured program policies, more flexible rules about discharge, more comprehensive assessment, and more outpatient mental health aftercare were associated with lower casemix-adjusted readmission rates. More intensive treatment was associated with higher-than-predicted readmission. By contrast, among younger patients, more family involvement in assessment and treatment, community consultation, and treatment emphasizing the development of social and work skills were associated with lower casemix-adjusted readmission rates. The findings suggest that intensive, directed treatment may be more effective for younger substance abuse patients, whereas a more supportive treatment regimen in a well-organized program and prompt outpatient aftercare may be especially helpful for older patients.

Rates and predictors of four-year readmission among late-middle-aged and older substance abuse patients.

This naturalistic study examines treatment, diagnoses and readmission among late-middle-aged and older (age 55+) substance abuse inpatients (N = 16,066) in Department of Veterans Affairs Medical Centers. Over an interval extending from 4 years before to 4 years after an index episode of care, older substance abuse patients used substantial amounts of inpatient and outpatient treatment. Service use was heaviest among patients with a concomitant psychiatric disorder, and there was no evidence that it declined over time in the overall group. Four-year readmission rates in three diagnostic subgroups (alcohol or drug dependence diagnosis only, alcohol or drug psychoses, substance dependence and/or psychoses with one or more psychiatric diagnoses) were very high (57% to 70%); however, they were somewhat lower among patients with less chronic substance abuse problems. Readmission and multiple readmission were predicted by younger age, unmarried status, more prior service use, alcohol psychosis or psychiatric diagnoses, treatment in a psychiatric unit, and shorter hospital stay. These factors may be used at admission and discharge to identify patients at risk for rehospitalization; inpatient treatment and aftercare can be planned accordingly.

Diagnostic subgroups and predictors of one-year re-admission among late-middle-aged and older substance abuse patients.

This naturalistic study uses data based on clinical records to examine treatment utilization and 1-year re-admission rates among three diagnostic subgroups of late-middle-aged and older substance abuse inpatients in Department of Veterans Affairs (VA) Medical Centers: inpatients with only an alcohol or drug dependence diagnosis (n = 11,652); inpatients with an alcohol or drug psychosis (n = 3,510); and inpatients with an alcohol or drug disorder and a concomitant psychiatric disorder (n = 5,977). As expected, substance abuse patients in the latter two subgroups received more treatment before, during and following an index episode of care than did patients with only an alcohol or drug dependence diagnosis. From a broad perspective, these results indicate a match between treatment services and patient needs. However, relatively few older substance abuse patients received outpatient mental health aftercare; this was true especially of patients with alcohol or drug psychosis diagnoses. The 1-year re-admission rate in the group overall was higher than that usually reported in younger and mixed-age groups of substance abuse patients. Re-admission was predicted by unmarried status (a predisposing factor) and need, as indexed by several diagnostic and treatment characteristics.

Mortality rates and predictors of mortality among late-middle-aged and older substance abuse patients.

This study describes mortality rates and predictors of mortality among late-middle-aged and older (55+) substance abuse inpatients (n = 21,139) in Department of Veterans Affairs (VA) Medical Centers in the 4 years after an index episode of care. A total of 24% of the patients died; this mortality rate was 2.64 times higher than expected. Predictors of earlier mortality included older age and nonmarried status, alcohol psychosis and organic brain disorder diagnoses, and several medical diagnoses, including neoplasms, liver cirrhosis, respiratory, endocrine and metabolic, and blood system disorders. Three proxy indicators of illness severity also predicted mortality: more prior inpatient and outpatient medical care and an index episode in an extended care unit. In contrast, more prior outpatient mental health care and remitted status predicted lower mortality. These diagnostic and treatment indicators can be used to identify patients at heightened risk for premature mortality. Moreover, they show that intensive mental health aftercare and remission of substance abuse may delay mortality, even among older patients who have longstanding substance abuse problems.

Personal and environmental risk factors as predictors of alcohol use, depression, and treatment-seeking: a longitudinal analysis of late-life problem drinkers.

We examined how personal risk factors (prior functioning, male, unmarried, early onset of drinking problems, and avoidance coping) and environmental risk factors (negative life events, chronic stressors, and friends' approval of drinking) predicted changes in older problem drinkers' (N = 659) adaptation over a 1-year interval. Personal risk factors independently predictive of poorer outcomes included poorer prior functioning, being male, and more use of avoidance coping strategies. Of environmental risk factors, negative life events, chronic health and spouse stressors, and having more friends who approved of drinking were independent predictors of poorer follow-up functioning and treatment seeking. Interactions between personal and environmental risk factors helped predict subsequent alcohol consumption and treatment seeking. For example, lighter drinkers were more likely than heavier drinkers to curtail alcohol use in response to new health events; friends more strongly influenced the treatment seeking of unmarried problem drinkers and individuals who used more avoidance coping strategies.

Patterns of diagnosis and treatment among late-middle-aged and older substance abuse patients.

This study examines the diagnoses and treatment received by a cohort (N = 22,678) of late-middle-aged and older substance abuse patients. More than 23% of substance abuse inpatients admitted to Department of Veterans Affairs (VA) Medical Centers in fiscal year 1987 were 55 years of age or older. Most of these patients had multiple health problems. More than 90% had an alcohol-related diagnosis; almost 30% were diagnosed with a psychiatric disorder; and more than 80% had a medical disorder. Compared with their younger counterparts, older substance abuse patients were less likely to receive specialized inpatient or outpatient treatment specifically directed toward their substance abuse or psychiatric problems. In general, older substance abuse patients received services oriented more toward medical management than toward rehabilitative substance abuse or psychiatric care. These findings imply a need to develop treatment programs tailored to the characteristics and substance abuse problems of older patients, and to encourage more use of specialized outpatient aftercare services by these individuals.

Evolution of an automated ST-segment analysis program for dynamic real-time, noninvasive detection of coronary occlusion and reperfusion.

Patients in whom early and stable reperfusion through the infarct artery fails after thrombolytic treatment might benefit from further revascularization therapy. A reliable noninvasive technique able to detect both reperfusion and reocclusion would be useful to test this hypothesis. However, no such technique presently exists. ST-segment recovery analysis using continuous digital 12-lead ST monitoring has been shown to be an accurate predictor of infarct artery patency in real time. This method was dependent on a trained clinician's analysis of the recordings on a personal computer. For optimal bedside application, salient principles of this ST-segment recovery analysis were converted into algorithms and built into the ST monitor software. The essentials of these algorithms are described in this report.