Janet R. Hankin

Morbidity in childhood - A longitudinal view

We examined all the morbidity experienced in a six-year period by a total of 2591 children who were continuously enrolled in a prepaid medical plan. The children had received 19,291 diagnoses, each of which was assigned to one of 14 types of morbidity, and the frequency of each type was determined. Although the typical child had at least one problem in 5 of the 14 types of morbidity in the six-year period, over 20 per cent of children had at least 8 different types of problems during that time. Children with a greater variety of acute problems and more frequent acute problems were also more likely to have nonacute problems during the six-year period. Conversely, children with nonacute problems had more acute problems than other children. Our findings indicate that morbidity, like use of health services, occurred in clusters in this population of children. Therefore, an understanding of the cause and projected outcome of morbidity among children will be incomplete if the focus is only on specific diseases or specific types of illnesses.

Family health. Utilization and effects of family membership.

The purpose of this study was to determine the extent to which members of families have similar and interralated health behavior. Utilization and morbidity data from more than 80,000 ambulatory visits by 693 families enrolled in a prepaid health plan for 6 consecutive years were examined using family membership as the major unit of analysis. Family members were found to resemble one another in their rates of use of services (r = 0.44; P< 0.001). Parental influence on childrens utilization is significant, mothers generally being two to three times more powerful than fathers in this regard. Apart from family size, structural characteristics of families contribute little to family health behavior. Family membership explains nearly one third of the variance of individual utilization even after family size and age and sex of family members are considered. A small proportion of families (5%) accounts for a disproportionately large share (12.3%) of health care utilization. Intrafamilial patterns of morbidity were apparent for several major groupings of diagnoses, most notably for acute health problems. Intrafamilial correlation were greatest among high-utilizing families. Families establish patterns of health behavior that are stable over time and therefore may be amenable to selective interventions. We conclude that health care planning, whether for service delivery or health education intervention, should consider family health data as an important information source.

The persistence of depressive symptomatology among prepaid group practice enrollees: an exploratory study.

This exploratory study examines the persistence of depressive symptomatology as measured by the Center for Epidemiological Studies Depressive Scale (CES-D). Over as 12-month period, half of the group of 309 prepaid group practice enrollees reporting depressive symptoms at the beginning of the interval also had high scores on the CES-D at the end of the interval. Sociodemographic characteristics did not predict persistence of depression. Persistence of depression was positively associated with initially reporting cognitive and affective types of depressive symptoms, the presence of physical illness, the seeking of psychiatric treatment, and the receipt of psychotropic drug prescriptions.

Episodes of psychiatric utilization

The continued growth of outpatient psychiatric care has been accompanied by a large number of research studies concerning the determinants of psychiatric utilization. One of the major limitations of these efforts has been the inability to go beyond distributional data on the use of services. This article describes a methodology for generating episodes of psychiatric care given a data set with a small amount of routinely collected data present in many medical information systems. Both demographic and medical characteristics are significantly associated with health services resource use as defined by the number of visits in an episode. A model predicting recurrent episodes of care is also described. The general utility of this approach and the substantive implications of the specific results are discussed.

A longitudinal study of offset in the use of nonpsychiatric services following specialized mental health care

This study examines the use of nonpsychiatric services hy mentally ill persons following the receipt of specialized mental health care, frequently referred to as the “offset effect.” A total of 9,761 persons enrolled during 1975 in the Columbia Medical Plan, a prepaid group practice in Columbia, Maryland, were studied over a 5–year period. Enrollees were classified into three groups: Treated—mental disorder diagnosis in 1975 and specialized mental health care in 1975; Untreated—mental disorder diagnosis in 1975 but no specialized mental health care in that year; and Comparison—neither mental disorder diagnosis nor specialized mental health care in 1975. The nonpsychiatric utilization for these groups was compared for 1973–1977. Specialized mental health care appears to have a short–term effect on nonpsychiatric utilization by attenuating the peak in use. Mentally ill persons without specialized mental health care in 1975 also reduced their use of nonpsychiatric services in 1976–1977. The utilization changes were more likely to occur in primary care departments, rather than nonpsychiatric specialty care departments. A diagnosis of mental disorder in either 1973 or 1974 was associated with a larger offset effect.

Episodes of psychiatric care and medical utilization

This study examines the reduction in medical care utilization after mental health treatment, also known as the offset effect. With data from a computerized ambulatory care information system, an episode-of-care method is used to characterize the mental health care received by patients in a prepaid group practice. The characteristics of the psychiatric episodes, such as duration, type of therapy, and number of visits, are examined in relation to the degree of offset effects among psychiatric patients. The results indicate that offset effects are most pronounced for a variety of characteristics related to the psychiatric episode of care including brief, high-intensity therapy, treatment for transient rather than chronic mental illness, and individual rather than group therapies. Finally, this study replicates two major findings in the offset literature: the characteristic peaking of medical use before mental health care and the shortterm nature of the offset effect.

An analysis of short-term alcoholism treatment cost functions.

A number of alcohol treatment studies have documented variations in the average cost of treating alcoholics. However, these studies have provided little explanation for these variations. In this study, three major issues in the measurement of alcoholism treatment costs are investigated: 1) choice of treatment location, i.e., inpatient versus outpatient; 2) interaction of treatment locations in the estimation of costs; 3) impact of type of alcohol problem and comorbidities on treatment costs. The study includes an integrated framework that jointly estimates treatment location and treatment costs conditional on treatment location, concentrating on short-term alcoholism treatment and using insurance claims data to specify a 6-month period beginning with each individuals first treatment for alcoholism. The different treatment types subsumed in the categories alcohol abuse and alcohol dependence are also addressed. Results indicate that comorbidities are crucial in determining treatment location. Once treatment location is determined, however, their effects on treatment costs, while measurable, are statistically insignificant. Partial treatment effects, conditional on treatment location, differ substantially from full treatment effects, which are determined jointly with treatment location.

Identification and Care of Problems Associated With Alcohol Ingestion in Pregnancy

Fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) are fully preventable if alcohol use is separated from pregnancy. However, accomplishing this can be much harder than it might seem. This article describes some strategies for identification and treatment of women who drink during pregnancy.

Extent of depressive symptomatology among patients seeking care in a prepaid group practice

A total of 1921 consecutive adult patients seen in the Departments of Internal Medicine and Obstetrics-Gynaecology at a prepaid group practice completed a self-administered depressive symptomatology questionnaire, the Centre for Epidemiologic Studies Depression Scale (CES-D). New health practitioners and physicians, who were not mental health specialists, blindly judged the presence or absence of depressive symptomatology. Twenty-one per cent of the patients suffered from depressive symptoms according to the CES-D, but only 15% of these were judged to be depressed by their physician or new health practitioner. The variables which predict the recognition of depressive symptomatology are discussed.

The impact on utilization of a copayment increase for ambulatory psychiatric care.

The impact of a copayment increase on the utilization of psychiatric services in a prepaid group practice program is examined. Data are presented on utilization at the Columbia Medical Plan (Columbia, Maryland) two years before and two years after the copayment increase. There was a highly transient response to the increase in the copayment for psychiatric care. The year of the copayment increase was characterized by a small decline in the proportion of enrollees using psychiatric care, and a slight decrease in the utilization rate. These declines were short-lived, and utilization returned to previous levels one year after the copayment increase.