Fragmented ambulatory care and subsequent emergency department visits and hospital admissions among Medicaid beneficiaries.

OBJECTIVES: Results of previous studies of Medicare beneficiaries have shown that more fragmented ambulatory care is associated with more emergency department (ED) visits and hospital admissions. Whether this observation is generalizable to Medicaid beneficiaries is unknown. STUDY DESIGN: We conducted a 3-year retrospective cohort study in the 7-county Hudson Valley region of New York. We included 19,330 adult Medicaid beneficiaries who were continuously enrolled, were attributed to a primary care provider, and had 4 or more ambulatory visits in the baseline year. METHODS: We measured fragmentation using a modified Bice-Boxerman Index. Cox proportional hazards models were used to determine associations between fragmentation score and ED visits or, separately, hospital admissions, adjusting for age, gender, and chronic conditions. RESULTS: The average beneficiary had 15 ambulatory visits in the baseline year, spread across 5 providers, with the most frequently seen provider accounting for 48% of the visits. One-fourth of the sample had more than 20 ambulatory visits and more than 7 providers, with the most frequently seen provider accounting for fewer than 33% of visits. For every 0.1-point increase in fragmentation score, the adjusted hazard of an ED visit over 2 years of follow-up increased by 1.7% (95% CI, 0.5%-2.9%). Having more fragmented care was not associated with a change in the hazard of a hospital admission. CONCLUSIONS: Among Medicaid beneficiaries, having more fragmented care was associated with a modest increase in the hazard of an ED visit, independent of chronic conditions. Fragmented ambulatory care may be modifiable and may represent a novel target for improvement.

Extent of Health Care Fragmentation in Different Payer Populations: Evidence from the Hudson Valley of New York.

Health care fragmentation occurs when patients see multiple ambulatory providers, but no single provider accounts for a substantial proportion of visits. Most previous studies have measured fragmentation in Medicare, which may not be generalizable. The study objective was to compare the extent of fragmented ambulatory care across commercially insured, Medicare, and Medicaid populations. The authors conducted a cross-sectional study of adults (N = 256,047) in the Hudson Valley region of New York, who were continuously insured (through 5 commercial payers, Medicare, or Medicaid), were attributed to a primary care physician, and had ≥4 ambulatory visits in the study year. Fragmentation was calculated using a reversed Bice-Boxerman Index, which captures both dispersion of care across providers and the relative share of visits by each provider. Chi-square tests, t tests, and correlation were used to compare patient characteristics and patterns of care across payers. Patients with Medicare had more chronic conditions (45% had ≥5 chronic conditions) than patients with commercial insurance (20%) or Medicaid (23%) (P < 0.01). However, mean fragmentation scores were comparable across all 3 payer populations: 0.73 (commercial insurance), 0.74 (Medicare), 0.72 (Medicaid). The correlation between number of chronic conditions and fragmentation was weak across payers, ranging from r = 0.004 to r = 0.12. If the extent of fragmentation does not vary with payer type or with the number of chronic conditions, it suggests that the causes of fragmentation may be more numerous and more complex than medical need alone.

Fragmented ambulatory care and subsequent healthcare utilization among Medicare beneficiaries.

OBJECTIVES: We sought to determine the associations between fragmented ambulatory care and subsequent emergency department (ED) visits and hospital admissions, while considering possible interactions between fragmentation and number of chronic conditions. STUDY DESIGN: We conducted a cohort study over 3 years among 117,977 fee-for-service Medicare beneficiaries who were attributed to primary care physicians in a 7-county region of New York and had 4 or more ambulatory visits in the baseline year. METHODS: We calculated fragmentation scores using a modified Bice-Boxerman Index and, because scores were skewed, divided them into quintiles. We used Cox regression models to determine associations between fragmentation and ED visits and, separately, hospital admissions, stratifying by number of chronic conditions and adjusting for age, gender, number of ambulatory visits, and case mix. RESULTS: Among those with 1 to 2 or 3 to 4 chronic conditions, having the most (vs the least) fragmented care significantly increased the hazard of an ED visit and, separately, increased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 5 or more chronic conditions, having the most fragmented care significantly increased the hazard of an ED visit but decreased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 0 chronic conditions, having fragmented care was not associated with either outcome. CONCLUSIONS: The relationship between fragmented ambulatory care and subsequent utilization varies with the number of chronic conditions. Beneficiaries with a moderate burden of chronic conditions (1-2 or 3-4) appear to be at highest risk of excess ED visits and admissions due to fragmented care.

An evaluation of national birth certificate data for neonatal seizure epidemiology.

OBJECTIVE: Seizures are a common manifestation of neurologic dysfunction in neonates and carry a high risk for mortality and adverse long-term outcomes. U.S. birth certificates are a potentially valuable source for studying the epidemiology of neonatal seizures. However, the quality of the data is understudied. METHODS: We reviewed all U.S. birth records from 2003 to 2013 to describe the following: (1) rates of missing data, (2) evidence of underreporting, and (3) effect of the 2003 revision of the birth certificate form. We evaluated missingness by state, year, demographic, infant health, and medical care factors using bivariate analyses. To measure potential underreporting, we compared estimates to a published reference (0.95 per 1,000 term births). We developed criteria for data plausibility, and reported which states met these criteria. RESULTS: Of 22,834,395 live term births (≥36 weeks of gestation) recorded using the revised form from 2005 to 2015, there were 5,875 with neonatal seizures, suggesting an incidence of 0.26 per 1,000 term births, one fourth of the expected incidence. Although the overall degree of missing seizure data was low (0.5%), missingness varied significantly by state, year, demographic, infant health, and medical care factors. After the 2003 birth certificate form revision, missing data and evidence of potential underreporting increased. Nine states met criteria for plausibility. SIGNIFICANCE: The value of U.S. birth certificate data for neonatal seizure epidemiology is limited by biased missingness, evidence suggestive of underreporting, and changes in reporting subsequent to the 2003 revision. There are plausible data from nine states, which merit investigation for further research.

Healthcare Fragmentation and the Frequency of Radiology and Other Diagnostic Tests: A Cross-Sectional Study.

BACKGROUND: Fragmented ambulatory care has been associated with high rates of emergency department visits and hospitalizations, but effects on other types of utilization are unclear. OBJECTIVE: To determine whether more fragmented care is associated with more radiology and other diagnostic tests, compared to less fragmented care. DESIGN: We conducted a cross-sectional study using claims from five commercial payers for 2010. The study took place in the Hudson Valley, a seven-county region in New York State. PARTICIPANTS: We included adult patients who were insured through the participating payers and were attributed to a primary care physician in the region. We restricted the cohort to those with ≥4 ambulatory visits, as measures of fragmentation are not reliable if based on ≤3 visits (N = 126,801). MAIN MEASURES: For each patient, we calculated fragmentation using a reversed Bice-Boxerman Index, which we divided into seven categories. We used negative binomial regression to determine the association between fragmentation category and rates of radiology and other diagnostic tests, stratified by number of chronic conditions and adjusting for patient age, gender, and number of visits. KEY RESULTS: Patients with the most fragmented care had approximately twice as many radiology and other diagnostic tests as patients with the least fragmented care, across all groups stratified by number of chronic conditions (each adjusted p < 0.0001). For example, among patients with ≥5 chronic conditions, those with the least fragmented care had 258 tests per 100 patients, and those with the most fragmented care had 542 tests per 100 patients (+284 tests per 100 patients, or +110 %, adjusted p < 0.0001). CONCLUSION: More fragmented care was independently associated with higher rates of radiology and other diagnostic tests than less fragmented care.

Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care.

A large proportion of the US population suffers from mental illness. Limited access to psychiatrists may be a contributor to the underuse of mental health services. We studied changes in the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists. During this period the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction in the median number of psychiatrists per 100,000 residents in hospital referral regions. In contrast, the numbers of primary care physicians and neurologists grew during the study period. These findings may help explain why patients report poor access to mental health care. Future research should explore the impact of the declining psychiatrist supply on patients and investigate new models of care that seek to integrate mental health and primary care or use team-based care that combines the services of psychiatrists and nonphysician providers for individuals with severe mental illnesses.

Predictors of All-Cause Mortality in Patients With Severe COPD and Major Depression Admitted to a Rehabilitation Hospital.

BACKGROUND: COPD is a major cause of all-cause mortality. We examined predictors of 1-year mortality in patients with severe COPD and major depression after inpatient treatment in a rehabilitation hospital. METHODS: We screened 898 consecutively admitted patients. Of these, 138 patients received the diagnoses of COPD according to American Thoracic Society Guidelines and major depression by Diagnostic and Statistical Manual of Mental Disorders, 4th edition and signed consent; 67 were randomized to a treatment adherence enhancement intervention and 71 to usual care. We assessed history of falls, dyspnea-related disability, severity of depression, medical burden, and cognitive functioning. Following discharge from inpatient rehabilitation, participants were prospectively followed, and mortality was ascertained over 52 weeks from hospital notes and reports of primary care physicians and relatives. RESULTS: One-year, all-cause mortality was 22% (31 of 138). Multivariate Cox regression analysis showed that history of falls in the 6 months preceding hospital admission was the strongest predictor of mortality (OR, 3.05; 95% CI, 1.40-6.66; P < .005). Dyspnea during activities (Pulmonary Functional Status and Dyspnea Questionnaire-Modified domain) was also associated with mortality (OR, 1.05; 95% CI, 1.02-1.08; P < .002). Depression severity, medical burden, and cognitive impairment were not predictors of mortality. CONCLUSIONS: Recent falls and dyspnea during activities identify subgroups of depressed patients with COPD at increased risk for all-cause mortality. These subgroups are in need of clinical attention and follow-up and can serve as targets for prevention research aiming to inform clinical strategies and public health planning.

Clinical Case Management versus Case Management with Problem-Solving Therapy in Low-Income, Disabled Elders with Major Depression: A Randomized Clinical Trial.

OBJECTIVE: To test the hypotheses that (1) clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in reducing depressive symptoms of depressed, disabled, impoverished patients and that (2) development of problem-solving skills mediates improvement of depression. METHODS: This randomized clinical trial with a parallel design allocated participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Two hundred seventy-one individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST. Participants were at least 60 years old with major depression measured with the 24-item Hamilton Depression Rating Scale (HAM-D), had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. RESULTS: CM and CM-PST led to similar declines in HAM-D over 12 weeks (t = 0.37, df = 547, p = 0.71); CM was noninferior to CM-PST. The entire study group (CM plus CM-PST) had a 9.6-point decline in HAM-D (t = 18.7, df = 547, p <0.0001). The response (42.5% versus 33.3%) and remission (37.9% versus 31.0%) rates were similar (χ(2) = 1.5, df = 1, p = 0.22 and χ(2) = 0.9, df = 1, p = 0.34, respectively). Development of problem-solving skills did not mediate treatment outcomes. There was no significant increase in depression between the end of interventions and 12 weeks later (0.7 HAM-D point increase) (t = 1.36, df = 719, p = 0.17). CONCLUSION: Organizations offering CM are available across the nation. With training in CM, their social workers can serve the many depressed, disabled, low-income patients, most of whom have poor response to antidepressants even when combined with psychotherapy.

Effects of Problem-Solving Therapy and Clinical Case Management on Disability in Low-Income Older Adults.

OBJECTIVE: To test the following hypotheses: (1) Clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in improving functional outcomes in disabled, impoverished patients and (2) improvement in depression, self-efficacy, and problem-solving skills mediates improvement of disability. METHODS: Using a randomized controlled trial with a parallel design, 271 individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Participants were at least age 60 years with major depression, had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. The WHO Disability Assessment Scale was used. RESULTS: Both interventions resulted in improved functioning by 12 weeks (t = 4.28, df = 554, p = 0.001), which was maintained until 24 weeks. Contrary to hypothesis, CM was noninferior to CM-PST (one-sided p = 0.0003, t = -3.5, df = 558). Change in disability was not affected by baseline depression severity, cognitive function, or number of unmet social service needs. Improvements in self efficacy (t = -2.45, df = 672, p = 0.021), problem-solving skill (t = -2.44, df = 546, p = 0.015), and depression symptoms (t = 2.25, df = 672, p = .025) by week 9 predicted improvement in function across groups by week 12. CONCLUSION: CM is noninferior to CM-PST for late-life depression in low-income populations. The effect of these interventions occur early, with benefits in functional status maintained as long as 24 weeks after treatment initiation (clinicaltrials.gov; NCT00540865).

Comparing engage with PST in late-life major depression: a preliminary report.

OBJECTIVE: The complexity of psychotherapies has been a barrier to community implementation. We used the Research Domain Criteria consensus as a guide to develop Engage, a streamlined, neurobiology-based psychotherapy for late-life depression that may match the skill set of practicing clinicians. This proof of concept study tested the hypotheses that Engage is bioequivalent to Problem Solving Therapy (PST) in reducing depressive symptoms, inducing remission, and ameliorating disability. METHODS: Engage assumes that abnormal function of the positive valence systems fuels depression and uses "reward exposure" (engagement in meaningful, rewarding activities) as its principal intervention. Negativity bias, apathy, and emotional dysregulation are expressions of abnormalities in the negative valence, arousal and regulatory, and cognitive control systems, respectively. Engage targets each of them with simple interventions only if they interfere with reward exposure. We treated openly, with 9 weekly sessions of Engage, 39 older adults with unipolar major depression. We compared their course of depression (HAM-D), remission rate (HAM-D<10), and disability (WHODAS) with those of a historical comparison group (N = 97) treated with 9 weekly sessions of PST. RESULTS: Community social workers and research therapists required one third as much training time in Engage as in PST. Engage was non-inferior to PST in reducing HAM-D and WHODAS. Remission rates for Engage at 6 and 9 weeks were 18.2% and 41.1%, respectively. The corresponding figures for PST were 13.7% and 35.0%, respectively. CONCLUSION: These initial observations suggest that Engage has comparable efficacy with PST in reducing depressive symptoms and disability and warrants a randomized controlled trial.

Apathy in late-life depression: common, persistent, and disabling.

OBJECTIVE: The aims of this study were to examine: (1) the relationship between apathy and disability in late-life depression, and (2) the functional significance of improvement in apathy following escitalopram treatment in terms of its relationship to disability. METHODS: Subjects were 71 non-demented elderly with non-psychotic major depression. After a 2-week single-blind placebo period, subjects who had Hamilton Depression Rating Scale (HDRS) ≥ 18 received escitalopram 10 mg daily for 12 weeks. Apathy and disability were assessed with the Apathy Evaluation Scale (AES) and the World Health Organization Disability Assessment Scale II (WHODAS), respectively. These measures and the HDRS were administered at baseline and again following 12 weeks of treatment. RESULTS: At baseline, 38% of depressed subjects had significant apathy (AES ≥ 36.5). Severity of apathy at baseline significantly correlated with severity of disability. In a multivariate regression model, baseline severity of apathy, but not the overall depressive syndrome (HDRS), significantly correlated with baseline disability. Following escitalopram treatment, improvement in apathy significantly correlated with improvement in disability measures, while change in the rest of the depressive syndrome did not. The overall change in apathy and disability in response to escitalopram treatment was significant but small. CONCLUSION: Apathy is common in late-life depression and is associated with disability above and beyond the influence of other depressive symptoms. Given the strong relationship between apathy and disability, understanding the neurobiology of apathy and developing treatments for apathy may improve the functional outcomes of late-life depression.

Executive functioning complaints and escitalopram treatment response in late-life depression.

OBJECTIVE: Executive dysfunction may play a key role in the pathophysiology of late-life depression. Executive dysfunction can be assessed with cognitive tests and subjective report of difficulties with executive skills. The present study investigated the association between subjective report of executive functioning complaints and time to escitalopram treatment response in older adults with major depressive disorder (MDD). METHODS: 100 older adults with MDD (58 with executive functioning complaints and 42 without executive functioning complaints) completed a 12-week trial of escitalopram. Treatment response over 12 weeks, as measured by repeated Hamilton Depression Rating Scale scores, was compared for adults with and without executive complaints using mixed-effects modeling. RESULTS: Mixed effects analysis revealed a significant group × time interaction, F(1, 523.34) = 6.00, p = 0.01. Depressed older adults who reported executive functioning complaints at baseline demonstrated a slower response to escitalopram treatment than those without executive functioning complaints. CONCLUSION: Self-report of executive functioning difficulties may be a useful prognostic indicator for subsequent speed of response to antidepressant medication.

The salience network in the apathy of late-life depression.

OBJECTIVE: Apathy is prevalent in late-life depression and predicts poor response to antidepressants, chronicity of depression, disability, and greater burden to caregivers. However, little is known about its neurobiology. Salience processing provides motivational context to stimuli. The aim of this study was to examine the salience network (SN) resting-state functional connectivity (rsFC) pattern in elderly depressed subjects with and without apathy. METHODS: Resting-state functional MRI data were collected from 16 non-demented, non-MCI, elderly depressed subjects and 10 normal elderly subjects who were psychotropic-free for at least 2 weeks. The depressed group included 7 elderly, depressed subjects with high comorbid apathy and 9 with low apathy. We analyzed the rsFC patterns of the right anterior insular cortex (rAI), a primary node of the SN. RESULTS: Relative to non-apathetic depressed elderly, depressed elderly subjects with high apathy had decreased rsFC of the rAI to dorsal anterior cingulate and to subcortical/limbic components of the SN. Depressed elderly subjects with high apathy also exhibited increased rsFC of the rAI to right dorsolateral prefrontal cortex and right posterior cingulate cortex when compared to non-apathetic depressed elderly. CONCLUSIONS: Elderly depressed subjects with high apathy display decreased intrinsic rsFC of the SN and an altered pattern of SN rsFC to the right DLPFC node of the central executive network when compared to elderly non-apathetic depressed and normal, elderly subjects. These results suggest a unique biological signature of the apathy of late-life depression and may implicate a role for the rAI and SN in motivated behavior.

Untangling therapeutic ingredients of a personalized intervention for patients with depression and severe COPD.

OBJECTIVE: We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobilize patients to participate in the care of both conditions. We showed that PID-C reduced depressive symptoms and dyspnea-related disability more than usual care over 28 weeks. This study focused on untangling key therapeutic ingredients of PID-C. DESIGN: Randomized controlled trial. SETTING: Community. PARTICIPANTS: 138 patients who received the diagnoses of COPD and major depression after screening 898 consecutive admissions for acute inpatient pulmonary rehabilitation. INTERVENTION: Nine sessions of PID-C compared with usual care over 28 weeks. MEASUREMENTS: Primary outcome measures were the 17-item Hamilton Depression Rating Scale and the Pulmonary Functional Status and Dyspnea Questionnaire-Modified. Other measures were adherence to rehabilitation exercise (≥2 hours per week) and adherence to adequate antidepressant prescriptions. RESULTS: Low severity of dyspnea-related disability and adherence to antidepressants predicted subsequent improvement of depression. Exercise and low depression severity predicted improvement of dyspnea-related disability. CONCLUSIONS: PID-C led to an interacting spiral of improvement in both depression and disability in a gravely medically ill population with a 17% mortality rate over 28 weeks and an expected deterioration in disability. The interrelationship of the course of depression and dyspnea-related disability underscores the need to target adherence to both antidepressants and chronic obstructive pulmonary disease rehabilitation. PID-C may serve as a care management model for depressed persons suffering from medical illnesses with a deteriorating course.

Personalised intervention for people with depression and severe COPD.

Chronic obstructive pulmonary disease (COPD) is often complicated by depression and exemplifies the challenge in managing chronic illnesses that require active patient participation in care. In a clinical trial (NCT00151372), we compared a novel personalised intervention for depression and COPD (PID-C) targeting treatment adherence with treatment as usual (TAU). In 138 patients with major depression and severe COPD, PID-C led to a higher remission rate and a greater reduction in depressive symptoms and in dyspnoea-related disability than TAU over 28 weeks and 6 months after the last session. If replicated, PID-C may serve as a care model for patients with both depression and medical illnesses with a deteriorating course.

Functional connectivity in apathy of late-life depression: a preliminary study.

BACKGROUND: Apathy is common in late-life depression and is associated with disability and poor antidepressant response. This study examined whether resting functional connectivity (FC) of the nucleus accumbens (NAcc) and the dorsal anterior cingulate (dACC) with other structures can distinguish apathetic depressed older patients from non-apathetic depressed patients and normal subjects. METHODS: Twenty-six non-demented, non-MCI older adults were studied. Of these, 16 had major depression (7 also had apathy) and 10 had no psychopathology. Resting state fMRI was performed prior to treatment in subjects who were psychotropic-free for at least two weeks. FC was determined by placing seeds in the NAcc and the dACC bilaterally. RESULTS: Apathetic depressed patients had lower FC of the NAcc with the amygdala, caudate, putamen, globus pallidus, and thalamus and increased FC with the dorsomedial prefrontal cortex, the superior frontal cortex, and the insula than non-apathetic patients. Further, apathetic patients had lower FC of the dACC with dorsolateral and ventrolateral prefrontal cortices and higher FC with the insula and the orbitofrontal cortex than non-apathetic patients. LIMITATIONS: Small number of subjects, lack of random sampling, use of a 1.5T MRI scanner. CONCLUSIONS: This preliminary study suggests that FC between the NAcc and the dACC and structures related to reward and related behavioral responses constitute the functional topography of abnormalities characterizing apathy of late life depression. However, replication is needed.