The effects of integrating behavioral health into primary care for low-income children.

OBJECTIVE: To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs. DATA SOURCES: 2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan. STUDY DESIGN: We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis. PRINCIPAL FINDINGS: After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost. CONCLUSIONS: Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.

USPSTF is unable to recommend for or against lipid screening to identify multifactorial dyslipidaemia in childhood: no recommendation is not without consequences.

Paediatric lipid screening has been recommended for decades to identify youth at increased risk for early atherosclerotic disease but is controversial and not universally adopted. A 2016 review by the US Preventive Services Task Force (USPSTF) found inadequate evidence to recommend for or against lipid screening in childhood. In this Perspective article, we examine this controversial and important topic more broadly. We consider whether the USPSTF framework is asking the right questions, and whether the answers to these questions should be valued equally, whether the USPSTF questions are answerable and by what types of evidence and whether the burden of proof is appropriate. We argue that using a broader framework that includes the magnitude of potential benefits and harms, considering more types of evidence beyond randomised controlled trials, and more fully incorporating patient and parent perspectives could lead to more practical and more widely applicable guidance for practitioners, guide future research priorities and be more inclusive of patient priorities.

Stakeholders' Perspectives on Stakeholder-engaged Research (SER): Strategies to Operationalize Patient-centered Outcomes Research Principles for SER.

BACKGROUND: US federal funding agencies increasingly incentivize stakeholder-engaged research which represents a paradigm shift toward incorporating a range of stakeholders in research design, conduct, and dissemination. OBJECTIVES: We use qualitative methods to capture experience-based recommendations on how to operationalize 4 Patient-Centered Outcomes Research (PCOR) principles in stakeholder-engaged research, specifically: (1) reciprocal relationships; (2) colearning; (3) partnership; and (4) trust, transparency, and honesty. RESEARCH DESIGN: We conducted semistructured interviews with members of a stakeholder panel who participated in a 2-year comparative effectiveness study of cholesterol screening and treatment among young adults. SAMPLE: Participants included 8 young adults and parent panelists and 11 professional panelists (clinicians, researchers, policy developers, and disseminators). MEASURES: The interview guide included questions about the 4 PCOR principles and queried preferred strategies to attain them. Interview transcripts were analyzed using an a priori and emergent coding structure. RESULTS: Participants provided strategies to promote the 4 PCOR principles. Although some stakeholder-identified strategies were complementary, others conflicted due to (1) competing ideologies identified among the principles, and (2) distinct stakeholder preferences. Illustrative of competing ideologies, participants simultaneously preferred receiving relevant articles before calls (to facilitate colearning) but also minimal outside reading (to achieve partnership). Illustrative of distinct stakeholder preferences, young adult and parent panelists generally preferred calls to occur on weekends/evenings, whereas professional panelists preferred mid-week work hours. CONCLUSIONS: Our exploratory study provides stakeholder-identified strategies to achieve the 4 PCOR principles, and demonstrates the need to identify, acknowledge, and address potentially conflicting strategies due to the potential for competing ideologies or variation in stakeholder preferences.

Do observational studies using propensity score methods agree with randomized trials? A systematic comparison of studies on acute coronary syndromes.

AIMS: Randomized controlled trials (RCTs) are the gold standard for assessing the efficacy of therapeutic interventions because randomization protects from biases inherent in observational studies. Propensity score (PS) methods, proposed as a potential solution to confounding of the treatment-outcome association, are widely used in observational studies of therapeutic interventions for acute coronary syndromes (ACS). We aimed to systematically assess agreement between observational studies using PS methods and RCTs on therapeutic interventions for ACS. METHODS AND RESULTS: We searched for observational studies of interventions for ACS that used PS methods to estimate treatment effects on short- or long-term mortality. Using a standardized algorithm, we matched observational studies to RCTs based on patients' characteristics, interventions, and outcomes ('topics'), and we compared estimates of treatment effect between the two designs. When multiple observational studies or RCTs were identified for the same topic, we performed a meta-analysis and used the summary relative risk for comparisons. We matched 21 observational studies investigating 17 distinct clinical topics to 63 RCTs (median = 3 RCTs per observational study) for short-term (7 topics) and long-term (10 topics) mortality. Estimates from PS analyses differed statistically significantly from randomized evidence in two instances; however, observational studies reported more extreme beneficial treatment effects compared with RCTs in 13 of 17 instances (P = 0.049). Sensitivity analyses limited to large RCTs, and using alternative meta-analysis models yielded similar results. CONCLUSION: For the treatment of ACS, observational studies using PS methods produce treatment effect estimates that are of more extreme magnitude compared with those from RCTs, although the differences are rarely statistically significant.

Medical home services for children with behavioral health conditions.

OBJECTIVES: Whether medical services received by children and youth with behavioral health conditions are consistent with a Medical Home has not been systematically studied. The objectives of this study were to examine the variation among four behavioral health conditions in regard to services related to the Medical Home. METHODS: Cross-sectional analyses of the 2003 National Survey of Children's Health were conducted. Multiple logistic regression analyses tested the impact of behavioral health conditions on medical needs, on Medical Home components, and on likelihood of having a Medical Home overall. RESULTS: Autism, Depression/Anxiety, and Behavior/Conduct problems were associated with reduced likelihood of having a Medical Home, whereas Attention-Deficit Hyperactivity Disorder was associated with increased likelihood. All health conditions predicted increased access to a primary care physician (PCP) and a preventive visit in the past year. However, all were also associated with higher needs for specialty care and all behavioral health conditions except Attention-Deficit Hyperactivity Disorder were associated with difficulties accessing this care. CONCLUSIONS: A detailed examination of the receipt of services among children and youth with behavioral health conditions reveals two primary reasons why such care is less likely to be consistent with a Medical Home model: (1) parents are more likely to report needing specialty care; and (2) these needs are less likely to be met. These data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the Medical Home has more to do with difficulty accessing specialty care than with problems accessing quality primary care.