Benjamin Lê Cook

Trends in Smoking Among Adults With Mental Illness and Association Between Mental Health Treatment and Smoking Cessation

IMPORTANCE Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence. OBJECTIVES To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation. DESIGN, SETTING, AND PARTICIPANTS Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness. MAIN OUTCOMES AND MEASURES Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample). RESULTS Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005). CONCLUSIONS AND RELEVANCE Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

Pathways and Correlates Connecting Latinos' Mental Health With Exposure to the United States

OBJECTIVES We examined potential pathways by which time in the United States may relate to differences in the predicted probability of past-year psychiatric disorder among Latino immigrants as compared with US-born Latinos. METHODS We estimated predicted probabilities of psychiatric disorder for US-born and immigrant groups with varying time in the United States, adjusting for different combinations of covariates. We examined 6 pathways by which time in the United States could be associated with psychiatric disorders. RESULTS Increased time in the United States is associated with higher risk of psychiatric disorders among Latino immigrants. After adjustment for covariates, differences in psychiatric disorder rates between US-born and immigrant Latinos disappear. Discrimination and family cultural conflict appear to play a significant role in the association between time in the United States and the likelihood of developing psychiatric disorders. CONCLUSIONS Increased perceived discrimination and family cultural conflict are pathways by which acculturation might relate to deterioration of mental health for immigrants. Future studies assessing how these implicit pathways evolve as contact with US culture increases may help to identify strategies for ensuring maintenance of mental health for Latino immigrants.

Comparing Methods of Racial and Ethnic Disparities Measurement across Different Settings of Mental Health Care

INTRODUCTION The ability to track improvement against racial/ethnic disparities in mental health care is hindered by the varying methods and disparity definitions used in previous research. DATA Nationally representative sample of whites, blacks, and Latinos from the 2002 to 2006 Medical Expenditure Panel Survey. Dependent variables are total, outpatient, and prescription drug mental health care expenditure. METHODS Rank- and propensity score-based methods concordant with the Institute of Medicine (IOM) definition of health care disparities were compared with commonly used disparities methods. To implement the IOM definition, we modeled expenditures using a two-part GLM, adjusted distributions of need variables, and predicted expenditures for each racial/ethnic group. FINDINGS Racial/ethnic disparities were significant for all expenditure measures. Disparity estimates from the IOM-concordant methods were similar to one another but greater than a method using the residual effect of race/ethnicity. Black-white and Latino-white disparities were found for any expenditure in each category and Latino-white disparities were significant in expenditure conditional on use. CONCLUSIONS Findings of disparities in access among blacks and disparities in access and expenditures after initiation among Latinos suggest the need for continued policy efforts targeting disparities reduction. In these data, the propensity score-based method and the rank-and-replace method were precise and adequate methods of implementing the IOM definition of disparity.

Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003-2012.

ObjectivesTo conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012.MethodsSystematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria.ResultsWe found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed.ConclusionsRoma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.

Measuring Racial/Ethnic Disparities in Health Care: Methods and Practical Issues

OBJECTIVE To review methods of measuring racial/ethnic health care disparities. STUDY DESIGN Identification and tracking of racial/ethnic disparities in health care will be advanced by application of a consistent definition and reliable empirical methods. We have proposed a definition of racial/ethnic health care disparities based in the Institute of Medicines (IOM) Unequal Treatment report, which defines disparities as all differences except those due to clinical need and preferences. After briefly summarizing the strengths and critiques of this definition, we review methods that have been used to implement it. We discuss practical issues that arise during implementation and expand these methods to identify sources of disparities. We also situate the focus on methods to measure racial/ethnic health care disparities (an endeavor predominant in the United States) within a larger international literature in health outcomes and health care inequality. EMPIRICAL APPLICATION: We compare different methods of implementing the IOM definition on measurement of disparities in any use of mental health care and mental health care expenditures using the 2004-2008 Medical Expenditure Panel Survey. CONCLUSION Disparities analysts should be aware of multiple methods available to measure disparities and their differing assumptions. We prefer a method concordant with the IOM definition.

Racial-Ethnic Disparities in Substance Abuse Treatment: The Role of Criminal History and Socioeconomic Status

OBJECTIVE Among persons with substance use disorders, those from racial-ethnic minority groups have been found to receive substance abuse treatment at rates equal to or higher than those of non-Latino whites. Little is known about factors underlying this apparent lack of disparities. This study examines racial-ethnic disparities in treatment receipt and mechanisms that reduce or contribute to disparities. METHODS Black-white and Latino-white disparities in any and in specialty substance abuse treatment were measured among adult respondents with substance use disorders from the 2005-2009 National Survey on Drug Use and Health (N=25,159). Three staged models were used to measure disparities concordant with the Institute of Medicine definition, assess the extent to which criminal history and socioeconomic indicators contributed to disparities, and identify correlates of treatment receipt. RESULTS Treatment was rare (about 10%) for all racial-ethnic groups. Odds ratios for black-white and Latino-white differences decreased and became significantly less than 1 after adjustment for criminal history and socioeconomic status factors. Higher rates of criminal history and enrollment in Medicaid among blacks and Latinos and lower income were specific mechanisms that influenced changes in estimates of disparities across models. CONCLUSIONS The greater likelihood of treatment receipt among persons with a criminal history and lower socioeconomic status is a pattern unlike those seen in most other areas of medical treatment and important to the understanding of substance abuse treatment disparities. Treatment programs that are mandated by the criminal justice system may provide access to individuals resistant to care, which raises concerns about perceived coercion.

Measuring Trends in Racial/Ethnic Health Care Disparities

Monitoring disparities over time is complicated by the varying disparity definitions applied in the literature. This study used data from the 1996-2005 Medical Expenditure Panel Survey (MEPS) to compare trends in disparities by three definitions of racial/ethnic disparities and to assess the influence of changes in socioeconomic status (SES) among racial/ethnic minorities on disparity trends. This study prefers the Institute of Medicines (IOM) definition, which adjusts for health status but allows for mediation of racial/ethnic disparities through SES factors. Black—White disparities in having an office-based or outpatient visit and medical expenditure were roughly constant and Hispanic—White disparities increased for office-based or outpatient visits and for medical expenditure between 1996-1997 and 2004-2005. Estimates based on the independent effect of race/ethnicity were the most conservative accounting of disparities and disparity trends, underlining the importance of the role of SES mediation in the study of trends in disparities.

Measuring Racial/Ethnic Disparities across the Distribution of Health Care Expenditures

OBJECTIVE To assess whether black-white and Hispanic-white disparities increase or abate in the upper quantiles of total health care expenditure, conditional on covariates. DATA SOURCE Nationally representative adult population of non-Hispanic whites, African Americans, and Hispanics from the 2001-2005 Medical Expenditure Panel Surveys. STUDY DESIGN We examine unadjusted racial/ethnic differences across the distribution of expenditures. We apply quantile regression to measure disparities at the median, 75th, 90th, and 95th quantiles, testing for differences over the distribution of health care expenditures and across income and education categories. We test the sensitivity of the results to comparisons based only on health status and estimate a two-part model to ensure that results are not driven by an extremely skewed distribution of expenditures with a large zero mass. PRINCIPAL FINDINGS Black-white and Hispanic-white disparities diminish in the upper quantiles of expenditure, but expenditures for blacks and Hispanics remain significantly lower than for whites throughout the distribution. For most education and income categories, disparities exist at the median and decline, but remain significant even with increased education and income. CONCLUSIONS Blacks and Hispanics receive significantly disparate care at high expenditure levels, suggesting prioritization of improved access to quality care among minorities with critical health issues.

The Impact of Insurance Coverage in Diminishing Racial and Ethnic Disparities in Behavioral Health Services

OBJECTIVE To estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act. DATA SOURCES Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001-2003). STUDY DESIGN We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage. DATA COLLECTION Access to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age. PRINCIPAL FINDINGS Improving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups.However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity. CONCLUSIONS Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.

Adjusting for health status in non-linear models of health care disparities

This article compared conceptual and empirical strengths of alternative methods for estimating racial disparities using non-linear models of health care access. Three methods were presented (propensity score, rank and replace, and a combined method) that adjust for health status while allowing SES variables to mediate the relationship between race and access to care. Applying these methods to a nationally representative sample of blacks and non-Hispanic whites surveyed in the 2003 and 2004 Medical Expenditure Panel Surveys (MEPS), we assessed the concordance of each of these methods with the Institute of Medicine (IOM) definition of racial disparities, and empirically compared the methods’ predicted disparity estimates, the variance of the estimates, and the sensitivity of the estimates to limitations of available data. The rank and replace and combined methods (but not the propensity score method) are concordant with the IOM definition of racial disparities in that each creates a comparison group with the appropriate marginal distributions of health status and SES variables. Predicted disparities and prediction variances were similar for the rank and replace and combined methods, but the rank and replace method was sensitive to limitations on SES information. For all methods, limiting health status information significantly reduced estimates of disparities compared to a more comprehensive dataset. We conclude that the two IOM-concordant methods were similar enough that either could be considered in disparity predictions. In datasets with limited SES information, the combined method is the better choice.