Caring for People With Depression: Costs Among 43 Million Commercially Insured Patients With or Without Comorbid Illnesses.

BACKGROUND: Depression is a common comorbidity for patients with chronic medical conditions. Although the costs of treating chronic medical illness in combination with depression are believed to be significantly higher than the costs of treating each condition independently, few studies have formally modeled the cost consequences of mental health comorbidity. PURPOSE: To estimate the relative magnitude of the independent and synergistic contributions to health care costs from depression diagnosis and other chronic physical health conditions. METHODS: Cross-sectional, observational study using all individuals >18 years of age in the national Blue Cross Blue Shield (BCBS) Axis claims database (N = 43,872,144) from calendar year 2018. General linear models with and without interaction terms were used to assess the relative magnitude of independent and synergistic contributions to total annual health care costs of depression alone and in combination with coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes (both types 1 and 2), hypertension, and arthritis. RESULTS: The incremental annual cost associated with having a diagnosis of depression was $2,951 compared to $1,986-$6,251 for the other chronic physical conditions. The interaction between depression and chronic conditions accounted for less than one-hundredth of the amount of variation in costs explained by the main effects of depression and each chronic physical condition. CONCLUSIONS: The independent increase in total annual health care costs associated with a depression diagnosis was comparable to that of many common physical chronic conditions. This finding underscores the importance of health care service and payment models that acknowledge depression as an equal contributor to overall health care costs. The combination of depression and another chronic condition did not synergistically increase total annual health care costs beyond the increases in costs associated with each condition independently. This finding has implications for simplifying risk adjustment models.

It is widely believed that depression, when combined with other chronic physical conditions, systematically inflates health care costs. For example, it is assumed that the costs of caring for a patient with both depression and heart disease are higher than the costs of caring for each condition independently. Using a database that included 43 million commercially insured people in the United States, we found that the costs of care for patients with depression were comparable to the costs for patients with other chronic medical conditions. This result supports the need for mental health parity and for trained mental health care providers in medical settings. We then considered the costs of caring for people with depression with or with or without one of seven common chronic physical condition. Contrary to expectation, the combination of depression and any of the diagnoses appeared to have largely independent relationships with health care costs. The results contradict the suggestion that depression and chronic condition diagnoses act synergistically to inflate health care expenditures.

Inconsistencies in Adolescent Self-Reported Sexual Behavior: Experience from Four Randomized Controlled Trials.

To examine the degree, correlates, and implications of inconsistent self-report data on sexual risk behaviors of adolescents. We analyzed data from four longitudinal group-randomized controlled trials of evidence-based HIV/STI/pregnancy prevention programs in Texas and California from 2000 to 2010. Across- and within-time logical inconsistencies in sexual behavior survey responses were analyzed using multilevel logistic regression. Rates of any inconsistencies ranged from 12 to 18% across the four trials. In all trials, rates were higher in males than in females. Age, normative beliefs, and race/ethnicity were most strongly associated with inconsistencies. We found substantial rates of inconsistencies in adolescents' self-reports of their sexual behavior, which did not occur at random. Studies should routinely report observed rates of inconsistencies and methods used to adjust for them so that any biases in the population to which the study generalizes are understood by public health practitioners and policy-makers looking to adopt programs for their particular population.

Who Benefits from School-Based Teen Pregnancy Prevention Programs? Examining Multidimensional Moderators of Program Effectiveness Across Four Studies.

Recent research has suggested the importance of understanding for whom programs are most effective (Supplee et al., 2013) and that multidimensional profiles of risk and protective factors may moderate the effectiveness of programs (Lanza & Rhoades, 2012). For school-based prevention programs, moderators of program effectiveness may occur at both the individual and school levels. However, due to the relatively small number of schools in most individual trials, integrative data analysis across multiple studies may be necessary to fully understand the multidimensional individual and school factors that may influence program effectiveness. In this study, we applied multilevel latent class analysis to integrated data across four studies of a middle school pregnancy prevention program to examine moderators of program effectiveness on initiation of vaginal sex. Findings suggest that the program may be particularly effective for schools with USA-born students who speak another language at home. In addition, findings suggest potential positive outcomes of the program for individuals who are lower risk and engaging in normative dating or individuals with family risk. Findings suggest potential mechanisms by which teen pregnancy prevention programs may be effective.

Automatic detection of hand hygiene using computer vision technology.

OBJECTIVE: Hand hygiene is essential for preventing hospital-acquired infections but is difficult to accurately track. The gold-standard (human auditors) is insufficient for assessing true overall compliance. Computer vision technology has the ability to perform more accurate appraisals. Our primary objective was to evaluate if a computer vision algorithm could accurately observe hand hygiene dispenser use in images captured by depth sensors. MATERIALS AND METHODS: Sixteen depth sensors were installed on one hospital unit. Images were collected continuously from March to August 2017. Utilizing a convolutional neural network, a machine learning algorithm was trained to detect hand hygiene dispenser use in the images. The algorithm's accuracy was then compared with simultaneous in-person observations of hand hygiene dispenser usage. Concordance rate between human observation and algorithm's assessment was calculated. Ground truth was established by blinded annotation of the entire image set. Sensitivity and specificity were calculated for both human and machine-level observation. RESULTS: A concordance rate of 96.8% was observed between human and algorithm (kappa = 0.85). Concordance among the 3 independent auditors to establish ground truth was 95.4% (Fleiss's kappa = 0.87). Sensitivity and specificity of the machine learning algorithm were 92.1% and 98.3%, respectively. Human observations showed sensitivity and specificity of 85.2% and 99.4%, respectively. CONCLUSIONS: A computer vision algorithm was equivalent to human observation in detecting hand hygiene dispenser use. Computer vision monitoring has the potential to provide a more complete appraisal of hand hygiene activity in hospitals than the current gold-standard given its ability for continuous coverage of a unit in space and time.

Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges.

BACKGROUND: There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver. OBJECTIVE: To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange. DESIGN: Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics. PARTICIPANTS: PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company. MAIN MEASURES: Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed. KEY RESULTS: For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges. CONCLUSIONS: The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.

You-Me-Us: Results of a Cluster Randomized Trial of a Healthy Relationships Approach to Sexual Risk Reduction.

By middle adolescence, most young people have been involved in at least one romantic relationship, a context in which many sexual interactions occur. Indeed, researchers have suggested the importance of attending to relationships in programs focused on sexual risk, yet few evidence-based programs have a strong relationships focus. Our study examined the impact of a healthy relationship program called You-Me-Us that included a classroom curriculum and a school-wide peer norms approach. We evaluated the intervention using a small group randomized trial that included nine participating urban middle schools (defined as schools that include grades 6-8) in three urban school districts. We invited all 7th grade students within the study schools to enroll. Students completed three surveys during 7th and 8th grades (baseline plus two follow up surveys at 6 and 18 months following baseline). A total of 911 youth with positive consent and assent were enrolled in the study. Follow up survey response rates among those taking the baseline were 92% at 6 months and 80% at 18 months. Multilevel regression models were used to adjust for the correlation among students within the same school, and the correlation of repeated measurements taken on the same student over time. The intervention reduced vaginal sexual initiation by about half at the 6-month follow-up, and this approached significance. Further, youth in the intervention condition were less likely to believe it is okay for people their age to have vaginal sex without using condoms if the girl is on birth control. None of the remaining variables differed significantly by intervention condition. This study provides insights on using a healthy relationship approach for younger urban adolescents. This approach produced a programmatically significant reduction in sexual initiation that did not reach standard levels of statistical significance, and warrants further exploration.

Effects of Mental Health on the Costs of Care for Chronic Illnesses.

OBJECTIVE: The study examined whether comorbid low mental health functioning inflates the cost of treating a chronic disease. METHODS: Data were from the 2015 Medical Expenditure Panel Survey (N=33,893). Costs were estimated from medical records and self-reported health care use. The mental component summary (MCS) score of the 12-item Short Form (SF-12) was used as a measure of mental health status. A general linear model estimated costs with fixed effects for chronic disease (present or absent) and mental health functioning (lowest, middle, and highest MCS score tertiles indicating low, middle, and high levels of mental health functioning, respectively). The SF-12 physical component summary score was a covariate. Eight conditions (arthritis, chronic obstructive pulmonary disease [COPD], high cholesterol, cancer, diabetes, stroke, coronary heart disease, and asthma) were analyzed separately. RESULTS: For each analysis, presence or absence of the chronic condition had a strong impact on cost. Lower mental health functioning also had a significant impact on cost. However, the interaction between mental health functioning and chronic disease diagnoses was statistically significant for only three conditions and accounted for only a small variation in cost. Sensitivity analyses using MCS score as a continuous variable, using a log10 transformation of the cost variable, and focusing only on persons with scores on the extreme low end did not significantly alter the conclusions. CONCLUSIONS: Contrary to expectation, the combination of poor mental functioning and chronic disease diagnosis did not have a strong synergistic effect on cost. Mental and general medical conditions appear to have independent effects on health care costs.

Economic analysis in behavioral health: Toward application of standardized methodologies.

Health care remains the most expensive sector in the U.S. economy, now accounting for nearly 1 in every 5 dollars spent. The purpose of health care is to improve the health of populations. However, formal medical care is one of many alternatives for improving health. In order to make better use of scarce resources, cost-effectiveness methodologies have been developed to evaluate how to produce the most health within the constraints of available resources. Standardized cost-effectiveness methodologies are now commonly used in the evaluation of medical therapies and new technologies. However, these methods have rarely been employed for the evaluation of behavioral interventions. Behavioral interventions often use measures that are not generally applied in other areas of health outcomes research. A consequence of neglecting to employ standardized cost-effectiveness analysis is that behavioral, psychological, and environmental interventions may be left out of resource allocation discussions. The purpose of this paper is to review standardized approaches to cost-effectiveness analysis and to encourage their use for the evaluation of behavioral intervention programs. Application of standardized methods of cost-effectiveness analysis will allow direct comparisons between investing in behavioral interventions programs in comparison to a wide range of other alternatives. The methods are general and can be used to estimate the cost-effectiveness of social and environmental interventions in addition to traditional medical and surgical treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Replication of It's Your Game Keep It Real! in Southeast Texas.

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

Examining the Effects of an Adolescent Pregnancy Prevention Program by Risk Profiles: A More Nuanced Approach to Program Evaluation.

PURPOSE: The objective of the study was to examine whether latent class analysis (LCA) could (1) identify distinct subgroups of youth characterized by multiple risk and protective factors for early sexual initiation and (2) allow for a more nuanced assessment of the effects of a middle school program to prevent teen pregnancy/HIV/sexually transmitted infection. METHODS: LCA was applied to data from the baseline (seventh grade) sample of 1,693 sexually inexperienced students participating in a randomized controlled trial of It's Your Game…Keep It Real in Harris County, Texas. Multilevel analysis was applied within subgroups defined by the latent classes to assess for potential differential program effects. RESULTS: LCA identified 3 distinct profiles of youth: family disruption, other language household, and frequent religious attendance. Multilevel analyses found differential effects of the program across these profiles with a significant and substantial reduction (30%) in initiation of vaginal sex by ninth grade for students in the family disruption profile only. CONCLUSIONS: Application of LCA may hold promise for conducting more nuanced evaluations and refinements of behavior change interventions for youth.

Dual Contraceptive Method Use Among Youth in Alternative Schools.

Dual contraceptive method use, or using a highly effective contraceptive method plus a barrier method like condoms, is gaining attention as a strategy for preventing unplanned pregnancy and sexually transmitted diseases. We investigated rates of dual method use among a sample of youth in urban alternative schools, and explored the relationship between dual method use and sexual partner type. The study analyzed data from 765 students enrolled in 11 district-run continuation high schools in northern California. We explored the association between dual method use and sexual partner type (steady only, a mix of steady and non-steady, and non-steady only) using logistic regression. Differences in dual rates by partner type were statistically significant, with higher rates of dual methods use reported among young people reporting non-steady sexual partners only, as compared to those with steady partners only. The data illustrate that young people in alternative school settings could gain from further intervention on the benefits, skills, and challenges of using two methods of contraception as opposed to one with both steady and non-steady sexual partners.

It's Your Game Keep It Real in South Carolina: A Group Randomized Trial Evaluating the Replication of an Evidence-Based Adolescent Pregnancy and Sexually Transmitted Infection Prevention Program.

OBJECTIVES: To evaluate the effectiveness of an evidence-based HIV/sexually transmitted infection (STI)/pregnancy prevention program for middle schools implemented by school staff in South Carolina. METHODS: Twenty-four schools, representing 3143 youths, participated in a randomized trial from 2011 to 2014. Students completed surveys before programming (fall of seventh grade), after completing the 2-year It's Your Game…Keep It Real program (spring of eighth grade), and 1-year postprogram (spring of ninth grade). RESULTS: There was no statistically significant effect on initiation of vaginal sex between baseline and eighth grade. Significantly fewer students in the comparison condition reported initiating sex at ninth grade, relative to the intervention condition. No group differences existed on other behavioral outcomes that addressed sexual activity in the past 3 months at ninth grade. Seven of 26 psychosocial outcomes (3 knowledge, 1 attitude, 1 self-efficacy, 2 personal limits) were positively affected at eighth grade; 4 remained significant at ninth grade. CONCLUSIONS: The original studies' behavioral effects were not replicated in this population, possibly as a result of this being an effectiveness trial instead of an efficacy trial, counterfactual exposure design issues, or postprogram exposure to evidence-based programming.

Estimates of Intraclass Correlation Coefficients From Longitudinal Group-Randomized Trials of Adolescent HIV/STI/Pregnancy Prevention Programs.

INTRODUCTION: Group-randomized trials (GRTs) are one of the most rigorous methods for evaluating the effectiveness of group-based health risk prevention programs. Efficiently designing GRTs with a sample size that is sufficient for meeting the trial's power and precision goals while not wasting resources exceeding them requires estimates of the intraclass correlation coefficient (ICC)-the degree to which outcomes of individuals clustered within groups (e.g., schools) are correlated. ICC estimates vary widely depending on outcome, population, and setting, and small changes in ICCs can have large effects on the sample size needed to estimate intervention effects. This study addresses a gap in the literature by providing estimates of ICCs for adolescent sexual risk-taking outcomes under a range of study conditions. METHOD: Multilevel regression analyses were applied to existing data from four federally funded GRTs of school-based HIV/STI/pregnancy prevention programs to obtain a variety of ICC estimates. RESULTS: ICCs ranged from 0 to 0.15, with adjustment for covariates and repeated measurements reducing the ICC in the majority of cases. Minimum detectable effect sizes with 80% power and 0.05 significance levels ranged from small to medium Cohen's d (0.13 to 0.53) assuming 20 schools of 100 students each. CONCLUSIONS: This study provides the first known set of ICC estimates for investigators to use when planning studies of school-based programs to prevent sexual risk behaviors in youth. The results provide further evidence of the importance of using the appropriate adjusted ICC estimate at the design stage to maximize resources in costly GRTs.

Interventions to reduce sexual risk behaviors among youth in alternative schools: a randomized controlled trial.

PURPOSE: This paper presents results from a randomized controlled trial that assessed the short- and longer-term impact of a skills-based HIV/STI/pregnancy prevention curriculum, service learning, and the combination. METHODS: The study featured a four-arm experimental design involving 47 classrooms (765 youth) from continuation high schools. Classrooms were randomly assigned to one of four conditions: (1) HIV/STI/pregnancy prevention curriculum only; (2) service learning only; (3) HIV/STI/pregnancy prevention curriculum plus service learning; or (4) an attention control curriculum. Students completed 3 surveys over 18 months. Multi-level analysis was used to adjust for the correlation among students within the same classroom and school, and the correlation of repeated measurements. RESULTS: Participants were 53% male (mean age: 16.2 years). The majority of youth reported being Hispanic/Latino or African-American (37.9% and 22.3%, respectively). Students in the HIV/STI/pregnancy prevention curriculum condition were less likely to have vaginal intercourse without a condom in the 3 months prior to the survey [odds ratio (OR) = .58, p = .04]; these effects diminished by final follow-up. The program also significantly reduced students' exposure to risky situations. These changes were not significant in the service learning only or combined intervention conditions relative to control. CONCLUSION: This study is one of a few controlled studies of HIV/STI and pregnancy prevention programs in continuation settings, and suggests the curriculum was effective in changing selected risk behaviors in the short term.

Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school.

PURPOSE: To estimate the size and demographic characteristics of the lesbian, gay, bisexual, and transgender youth populations using data from the 2011 Youth Risk Behavior Survey (YRBS) administered in San Francisco Unified School District middle schools. METHODS: The YRBS was administered to a stratified random sample of 2,730 youth (grades 6-8) across all 22 public middle schools in San Francisco. Cross-tabulations using complex samples analyses were used to derive population estimates and confidence intervals. RESULTS AND CONCLUSIONS: Results show that 3.8% of middle school students identify as lesbian, gay, or bisexual, and 1.3% of middle school students identify as transgender. To improve our understanding of the size of these populations across the nation, researchers conclude it is imperative that all YRBS administration sites include items on sexual orientation and gender identity as they would any other demographic item, such as race/ethnicity, sex, or age. The current lack of reliable data on the size and characteristics of the lesbian, gay, bisexual, and transgender youth population limits the capacity of policy makers, administrators, and practitioners to address their needs.

Condom use: slippage, breakage, and steps for proper use among adolescents in alternative school settings.

BACKGROUND: School-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI), and pregnancy prevention programs often focus on consistent and correct condom use. Research on adolescents' experience using condoms, including condom slippage/breakage, is limited. This exploratory study examines proper condom use and the occurrence of condom slippage/breakage among alternative school youth. METHODS: Data are from an HIV/STI prevention trial for youth in continuation school settings (N = 776). Analyses included separate hierarchical logistic regression analyses to explore the relationship between potential correlates and each outcome variable. RESULTS: Students' use of steps for proper condom use varied-73.8% put on the condom before sexual contact, 71.1% squeezed air from the tip, and 92.0% unrolled the condom fully. Notably, 28.5% reported condom slippage/breakage. Results from the regression analyses showed that 4 sets of variables (demographic, substance use, sexual risk behaviors, and condom psychosocial factors) were associated with putting on a condom before sexual contact; none of the variable sets were associated with the other 2 condom steps measured. For slippage/breakage, the demographic and sexual risk behaviors were significant correlates; steps for proper condom use approached statistical significance (p = .058). CONCLUSIONS: This study extends the limited research on how adolescents use condoms, and highlights important targets for prevention interventions.

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students.

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.