Using drug claims data to assess the relationship of medication adherence with hospitalization and costs.

OBJECTIVE: This naturalistic study used claims data to examine the relationship of medication nonadherence to hospital use and costs among severely mentally ill clients in Wisconsin. METHODS: Data for 619 clients were obtained from Medicaid drug and hospital claims, county records, and case managers as part of a larger study in eight county-based mental health systems. Study participants were eligible for Medicaid, had a severe and persistent mental illness, were 18 years or older, and were receiving neuroleptics, lithium, or antidepressants. Drug claims were analyzed for a 12-month period to determine how regularly clients obtained their medications. Regression analyses were used to assess the effects of irregular medication use on any hospitalization for psychiatric problems, the number of days hospitalized, and hospital costs. The analyses controlled for several risk factors. RESULTS: Among clients with schizophrenia or schizoaffective disorder, 31 percent used medications irregularly. The rates were 33 percent among those with bipolar disorder and 41 percent among those with other severe mental illnesses. In the total sample, irregular users had significantly higher rates of hospitalization than regular users (42 percent versus 20 percent), more hospital days (16 days versus four days), and higher hospital costs ($3,992 versus $1,048). Irregular medication use was one of the strongest predictors of hospital use and costs even after the analyses controlled for diagnosis, demographic characteristics, baseline functioning, and previous hospitalizations. CONCLUSIONS: The availability of drug claims data and the ability to use them in predictive analyses make them a potentially useful data source in studies of medication adherence among persons with severe mental illness.

Work and social support: a comparison of consumers who have achieved stability in ACT and clubhouse programs.

A current debate in the field is whether consumers, who have achieved stability in Assertive Community Treatment programs, can be transferred to less intensive services. To bring some data to bear on this question, this study compared consumers and members, who have achieved stability, in either an Assertive Community Treatment (ACT) or a clubhouse program, on domains of vocational activity, social relationships/loneliness and community integration. The 51 stable clients from the two programs who were interviewed, reported similar vocational activity, similar experiences with social relationships and social networks, and similar community integration. Clients in both groups were less lonely than previously reported in the literature. Study results indicate, that for those clients who have achieved stability, there are sufficient similarities between consumers in the two programs, to suggest a potential for movement from more to less intensive programs with less disruption than previously assumed possible.

Mental health expenditures for services for people with severe mental illnesses.

OBJECTIVE: To provide comprehensive information on expenditures for mental health and substance abuse services for a large number of people with severe mental illnesses, this study examined use of major types of clinical-medical mental health and psychiatric rehabilitation services over a one-year period. METHODS: Data were obtained for 1,890 clients in ten public county-based nonmetropolitan mental health systems in Wisconsin. Expenditures were for services provided with public funding, including local sources of funding, Medicaid, and Medicare. Data about services and expenditures were obtained from county records and unduplicated Medicaid claims for 12 months in 1989 and 1990. RESULTS: Expenditures per client averaged $10,995 for one year ($13,992 in 1994 dollars), with a maximum of $95,093. Expenditures for community-based outpatient services, including residential care and vocational services, represented 53.5 percent of all expenditures; residential care accounted for 12.4 percent and vocational services for 5.7 percent. Overall, 46.5 percent was spent for institutional care, with inpatient hospital care accounting for 12.6 percent. Approximately 40.6 percent of total expenditures were for services not typically covered under managed care plans. CONCLUSIONS: Expenditures for community-based care accounted for more than half of total expenditures. Expenditure patterns revealed the important role of social and rehabilitation services, a role that must be continued in managed care arrangements if they are to provide adequate services for people with severe mental illnesses.

A review of occupational exposure in the North-Western Region.

The Ionizing Radiations Regulations 1985 require employers to monitor all classified persons and to demonstrate that all non-classified persons who work in controlled areas do not exceed three-tenths (i.e. the classification level) of any relevant annual dose limit. A review of occupational doses was undertaken to ascertain whether any person needed to be designated as a classified person and to demonstrate compliance with the Regulation regarding non-classified staff working in controlled areas. The occupational-dose data for 1986 were compared with data for 1981 to identify any areas where changes in workload, equipment or techniques had led to increases in whole-body or organ doses. The results demonstrate that the level of whole-body occupational dose received by the vast majority of NHS employees in the North-Western Regional Health Authority is, as expected, extremely low. However, two specific areas were identified where occupational doses are relatively high and need to be carefully monitored. The review has also led to a number of operational changes being implemented by the Approved Dosimetry Service.

Effects of unilateral brain damage on contralateral and ipsilateral upper extremity function in hemiplegia.

This article describes the long-term effects of unilateral penetrating hemispheric lesions on contralateral and ipsilateral upper extremity motor performance and functional outcome. Activities-of-daily-living skill and gross motor performance contralateral to the lesions were compared among 32 left-sided and 19 right-sided hemiplegic subjects using analysis of variance and chi-square techniques. Ipsilateral to the damaged hemisphere, fine motor tasks of simple visual motor reaction time, grip and pinch strength, finger tapping, and Purdue Pegboard performance were tested. Analysis of covariance compared each ipsilateral task to performance in the corresponding hand of 70 matched controls. Results indicate similar long-term functional ADL outcome in right and left hemisphere-damaged subjects, despite more severe contralateral functional motor deficits following lesions of the left hemisphere. Right hemisphere lesions led to ipsilateral decrements in reaction time, and lesions of either hemisphere diminished grip or pinch strength, finger tapping, and pegboard performance ipsilaterally. These results demonstrate that unilateral brain damage involving the motor areas of either hemisphere has detrimental effects on ipsilateral upper extremity motor function. Findings are discussed and related to the concept that the left hemisphere is specialized or has greater neuronal representation for bilateral motor processes. Physical therapists involved in the treatment of patients with hemiplegia should be aware that motor functions of the ipsilateral, nonparetic upper extremity may also be affected adversely by unilateral brain lesions.

Radiation dose to patient and staff during percutaneous nephrostolithotomy.

The radiation dose to the patient and to members of staff was monitored during 18 procedures for the percutaneous removal of renal stones. It was found that the radiation dose to the patient was minimal and was about the same as for an IVU. The overall dose to the staff was acceptably low and within safety limits. It was concluded that PCNL is a safe procedure from the radiation point of view but it may be advisable to take certain precautions if the workload is high.

Radiation doses and somatic risk to patients during cardiac radiological procedures.

The radiation dose to a series of adult and paediatric patients undergoing cardiac catheterisations and adults having percutaneous transluminal coronary angioplasty has been measured/determined directly using lithium fluoride thermoluminescent dosemeters and indirectly using an air ionisation chamber which indicated exposure-area product. Somatic and genetic risks are estimated from the dosimetry results. It is suggested that the magnitude of the radiation hazard is negligible compared with other clinical hazards associated with these procedures.

Vietnam head injury study. Preliminary analysis of the functional and anatomical sequelae of penetrating head trauma.

An overview is presented of the multidisciplinary design, specific methods of motor and functional assessment, and selected preliminary data trends from the Vietnam Head Injury Study. This longitudinal study combines analyses of retrospective records with current, comprehensive inpatient examinations and investigates the anatomical and functional sequelae of penetrating head trauma in 700 Vietnam Veterans at an average of 14 years after injury. Preliminary data analysis of results from the first 160 subjects demonstrates good functional recovery despite large brain lesions. Motor abnormalities have persisted in 28 percent of the sample and are correlated with lesions involving the frontoparietal area of the cortex and the deep midline brain structures. Design concepts and long-term outcome trends will be useful to therapists in neurological rehabilitation. The study provides a model for health-team members interested in designs for longitudinal collection of outcome data.