Clinical Care Quality Among Veterans Health Administration Patients With Mental Illness Following Medical Home Implementation.

OBJECTIVE: This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness. METHODS: VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators. RESULTS: The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50-64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease. CONCLUSIONS: Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.

Are hotshots always hot? A longitudinal study of hormones, behavior, and reproductive success in male marine iguanas.

Polygynous lek-mating systems are characterized by high reproductive skew, with a small number of males gaining a disproportionate share of copulations. In lekking species, where female choice drives male mating success and patterns of reproductive skew, female preferences for 'good genes' should lead to preferred males having high reproductive success in all years. Here we investigate whether these 'hotshot' males have steroid hormone patterns that are consistent over time (between two mating seasons), and whether hormone levels consistently predict display behavior. We test these questions in the Galápagos marine iguana (Amblyrhynchus cristatus), a lekking vertebrate with high male reproductive skew. We found that male mating success and testosterone levels were not consistent across years. The most successful males showed an inverse relationship in copulation success between years. Similarly, territorial males that had high testosterone in one year had low levels in the next. Across years, testosterone was strongly associated with head-bob display, suggesting that this steroid plays a key role in mate attraction. These results suggest that female marine iguanas are not choosing the same 'hotshot' males in every year, but instead base their reproductive decisions on male behavioral traits that are hormonally mediated and variable across years. By using testosterone to regulate their costly display behaviors male marine iguanas appear to have a mechanism that allows them to adjust their reproductive effort depending on extrinsic and/or intrinsic factors.