Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness.

Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. Design, Setting, and Participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration.

BACKGROUND: In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear. OBJECTIVE: To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement. METHODS: We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement. RESULTS: Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36). CONCLUSIONS: Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Association Between Virtual Care Use and Same-Day Primary Care Access in VA Primary Care-Mental Health Integration.

INTRODUCTION: Same-day referrals from primary care to mental health increase subsequent mental health treatment engagement. VA Primary Care-Mental Health Integration (PC-MHI) clinics offer integrated mental health services embedded in primary care clinics, providing a key entry point to mental health care. Although telehealth use expanded rapidly after the onset of COVID-19, the impact of telehealth on same-day primary care access among new PC-MHI mental health patients is unknown. To address this knowledge gap, we examined associations between telehealth use and same-day primary care access in VA PC-MHI. METHODS: We examined electronic health record data to identify same-day primary care appointments among PC-MHI patients who initiated care during 3/1/2018 to 10/29/2021. We used logistic regression analyses to evaluate the effect of telehealth on same-day primary care access. Time, demographic characteristics, mental health diagnoses (PTSD and depression), and substance use disorder diagnosis were evaluated as covariates. RESULTS: New PC-MHI patients who were seen via telehealth were less likely to receive same-day primary care access than patients seen in person (OR: 0.54; 95% CI: 0.41-0.71; P < .001). CONCLUSIONS: Despite the potential advantages of using telehealth to increase access, VA patients with an initial PC-MHI visit via telehealth were less likely than patients seen in person to be referred from primary care. Telehealth may adversely affect primary care referrals to mental health services, an outcome that could ultimately reduce specialty mental health care continuity. There is an urgent need to identify strategies to facilitate PC-MHI care coordination in the telehealth context.

Access to Care for Veterans With Serious Mental Illness During the COVID-19 Pandemic.

OBJECTIVE: The authors examined access to care among persons with serious mental illness during the pandemic and disparities in use of virtual care among this population versus among individuals with other psychiatric diagnoses. METHODS: Data from the Veterans Health Administration were used to examine whether the number of visits for serious mental illness differed for January-September 2019 versus the same period in 2020. Mixed-effects regression analyses tested whether the post-COVID-19 rate of growth in virtual care differed for people with serious mental illnesses versus those with other diagnoses. RESULTS: Fewer visits for serious mental illnesses occurred during the initial weeks of the pandemic but not subsequently. The rate of growth in video visits during 2020 was slower for serious mental illnesses than for other psychiatric diagnoses. CONCLUSIONS: Several months after the pandemic's start, the total number of visits for serious mental illnesses was similar to 2019; however, adoption of video care was slower than for other psychiatric diagnoses.

What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study.

Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

NPITxt, a 21st-Century Reporting System: Engaging Residents in a Lean-Inspired Process.

Operational waste, or workflow processes that do not add value, is a frustrating but nonetheless largely tolerated barrier to efficiency and morale for medical trainees. In this article, the authors tested a novel reporting system using several submission formats (text messaging, e-mail, Web form, mobile application) to allow residents to report various types of operational waste in real time. This system informally promoted "lean" principles of waste identification and continuous improvement. In all, 154 issues were submitted between March 30, 2011, and June 30, 2012, and categorized as closely as possible into lean categories of operational waste; 131 issues were completely addressed with the requested outcome partially or fully implemented or with successful clarification of existing policies. A real-time, voluntary reporting system can effectively capture trainee observations of waste in health care and training processes, give trainees a voice in a hierarchical system, and lead to meaningful operations improvement.

Vascular risk and FDDNP-PET influence cognitive performance.

The relationship of cerebrovascular risk and Alzheimer's disease (AD) pathology to cognition in pre-dementia has been extensively investigated and is well-established. Cerebrovascular risk can be measured using a Framingham Stroke Risk Profile (FSRP) score, while positron emission tomography (PET) scans with 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile (FDDNP) measure AD neuropathology (i.e., amyloid-ß plaques and tau tangles). Here we report results of 75 healthy non-demented subjects (mean age, 63 years) who underwent neuropsychological testing, physical assessments, and FDDNP-PET scans. Controlling for AD family history, education, and APOE4 status in a general linear model, higher FSRP risk and global FDDNP-PET binding were each associated with poorer cognitive functioning. The interaction of FSRP and global FDDNP-PET binding was not significant in the model, indicating that stroke risk and plaque and tangle burden each contributed to worse cognitive performance. Within our healthy volunteers, age, blood pressure, and antihypertensive medication use were vascular risks that contributed significantly to the above findings. These findings suggest that even mild cerebrovascular risk may influence the extent of cognitive dysfunction in pre-dementia, along with amyloid-ß and tau burden.

Microsurgical clipping and endovascular coiling of intracranial aneurysms: a critical review of the literature.

OBJECTIVE: Although endovascular coiling has been used for 15 years in the treatment of intracranial aneurysms, fewer than 60 published studies have directly compared microsurgical clipping and endovascular coiling, and only two studies have used a randomized, prospective design. The objective of this review is to weigh evidence for the efficacy of endovascular coiling compared with microsurgical clipping based on published head-to-head comparisons. METHODS: Two major electronic databases, PubMed and Cochrane Library, were queried using search terms such as "coiling," "clipping," "microsurgical," "endovascular," "Guglielmi," and "intracranial aneurysm." Relevant randomized trials and observational, cohort, and case studies of unruptured and ruptured aneurysms were considered for analysis. Data from included studies were summarized qualitatively, addressing study methodologies, patient demographics, study techniques/equipment, and outcome measures. RESULTS: Forty-seven studies were included in the final count, including two prospective randomized trials, 23 prospective observational studies, 20 retrospective observational studies, and two studies that used a combination of prospective and retrospective data. In total, 18 studies found outcomes to be equivalent in the coiled and clipped groups, 18 studies favored coiling, 10 studies favored clipping, and one study had no conclusion (in terms of a comparison). CONCLUSION: The earliest randomized prospective study by Koivisto et al. found clinical and angiographic results between the two methodologies to be statistically equivalent. The more recent and larger randomized, prospective study from the International Subarachnoid Aneurysm Trial group suggests that endovascular coiling is statistically superior to microsurgical clipping in clinical outcomes, although the recently published long-term follow-up of International Subarachnoid Aneurysm Trial patients documents higher recurrence and rehemorrhage rates after endovascular coiling. Although there is no clear consensus in these two studies or in the 45 observational studies included, clinically useful information can be extracted to improve shared decision making and interaction between interventionalists and neurosurgeons, create more individualized treatment algorithms, and enhance future research.

Cognitive deficits following coronary artery bypass grafting: prevalence, prognosis, and therapeutic strategies.

There is increasing recognition that coronary artery bypass grafting (CABG) may be a risk factor for subtle cognitive decline although the presence and pattern of such decline has varied across studies. Cognitive deficits may present as short-term memory loss, executive dysfunction and psychomotor slowing. Although they are usually are not severe enough to meet criteria for mild cognitive impairment or vascular dementia, they lower quality of life and add to hospitalization and out-of-hospital costs. Proposed mechanisms include surgical-related trauma, genetic susceptibility (eg, apolipoprotein E4 allele), microembolization, other vascular or ischemic changes, and temperature during surgery. Depression and anxiety levels predict subjective perception of these deficits more than objective cognitive performance. Both nonpharmacologic (eg, emboli reduction, temperature, or glucose management) and pharmacologic (eg, dexanabinol, glypromate, nootropics) strategies to prevent post-CABG cognitive deficits are under investigation. Given the large numbers of subjects who may already have CABG associated cognitive deficits, clinical trials of agents being tested for Alzheimer's disease (eg, donepezil, rivastigmine, memantine, neramexane, ginkgo) may also be informative. The results of multicenter long-term outcome studies (with matched control groups) as well as ongoing treatment trials will more conclusively address some of these issues. These data emphasize the need for clinicians to monitor cognitive function before and after coronary bypass surgery, and to educate patients.