Lily Zhang

Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder in a Managed Care Medicaid Program

OBJECTIVE To examine whether clinical severity is greater among children receiving attention-deficit/hyperactivity disorder (ADHD) care in primary care compared with those in specialty mental health clinics, and to examine how care processes and clinical outcomes vary by sector across three 6-month time intervals. METHOD This was a longitudinal cohort study of 530 children aged 5 to 11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, countywide managed care Medicaid program. RESULTS Clinical severity at study entry did not differ between children who received ADHD care in solely primary or specialty mental health care clinics. At three 6-month intervals, receipt of no care ranged from 34% to 44%, and unmet need for mental health services ranged from 13% to 20%. In primary care, 80% to 85% of children had at least one stimulant prescription filled and averaged one to two follow-up visits per year. Less than one-third of children in specialty mental health clinics received any stimulant medication, but all received psychosocial interventions averaging more than five visits per month. In both sectors, stimulant medication refill prescription persistence was poor (31%-49%). With few exceptions, ADHD diagnosis, impairment, academic achievement, parent distress, and parent-reported treatment satisfaction, perceived benefit, and improved family functioning did not differ between children who remained in care and those who received no care. CONCLUSION Areas for quality improvement are alignment of clinical severity with provider type, follow-up visits, stimulant use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatment, and stimulant medication refill prescription persistence.

Effectiveness of collaborative care in addressing depression treatment preferences among low-income Latinos.

OBJECTIVE This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. METHODS A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. RESULTS The conjoint analysis preference survey showed that patients preferred counseling or counseling plus medication over antidepressant medication alone and that they preferred treatment in primary care over specialty mental health care, but they showed no significant preference for individual versus group treatment. Patients also indicated that individual education sessions, telephone sessions, transportation assistance, and family involvement were barrier reduction strategies that would enhance their likelihood of accepting treatment. Compared with patients assigned to usual care, those in the intervention group were 21 times as likely to receive preferred treatment. Among all participants, women, unemployed persons, those who spoke English, and those referred by providers were more likely to receive preferred treatment. CONCLUSIONS Collaborative care interventions that include psychotherapy can increase the likelihood that Latino patients receive preferred care; however, special efforts may be needed to address preferences of working persons, men, and Spanish-speaking patients.

FAK activation and the role of epithelial membrane protein 2 (EMP2) in collagen gel contraction.

PURPOSE Proliferative vitreoretinopathy (PVR) occurs in approximately 10% of patients after retinal detachment. PVR results from a multiphase process that leads to an aberrant wound-healing strategy with contractile cellular forces and tractional retinal detachment (TRD). Epithelial membrane protein (EMP) 2 controls cell surface expression and function of integrin isoforms associated with cellular contraction in many cell types. Since EMP2 is highly expressed in retinal pigment epithelium, this study investigates the role of EMP2 in collagen gel contraction. METHODS EMP2 expression was recombinantly modified in the ARPE-19 cell line. Cell surface integrin expression was assessed by flow cytometry. Collagen gel contraction was assessed by using an in vitro assay and the percentage of contraction was quantified. Proliferation and migration were measured by BrdU incorporation and a wound-healing assay, respectively. Cellular invasion was investigated with polycarbonate membranes coated with collagen. RESULTS EMP2 expression levels correlated positively with the ability to contract collagen gels. Compared with wild-type ARPE-19 cells, the cells with increased EMP2 expression exhibited enhanced contraction (P = 0.02), and decreased EMP2 expression concomitantly resulted in decreased contraction (P = 0.002). EMP2 overexpression resulted in reduced proliferation, migration, and integrin alpha1 and alpha2 integrin expression. EMP2 overexpression was associated with a 70% increase in FAK activation (P = 0.0003) and relative resistance of gel contraction to inhibitors of FAK/Src activation. CONCLUSIONS ARPE-19-mediated collagen gel contraction is a multistep process that requires integrin ligation and activation of the FAK/Src complex. EMP2 positively modulates collagen gel contraction by ARPE-19 cells through increased FAK activation.

Mental Health Service Use by Older Adults: The Role of Chronic Pain

OBJECTIVE Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, the authors explored the role of chronic pain in mental health service use by adults according to age group. METHOD The authors conducted a cross-sectional analysis of survey data from the second wave of the Health Care for Communities telephone survey collected in 2000-2001. Participants consisted of U.S. civilian adults (N = 6629) from randomly selected U.S. households. Common mental disorders were assessed using the short-form versions of the World Health Organizations Composite International Diagnostic Interview. Chronic pain conditions and mental health services received were identified by self-report. Physical and mental functioning was assessed using the Short Form-12. RESULTS Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared with those aged 18-60 years. In multiple logistic regression models, an interaction effect was found between age and chronic pain (odds ratio: 3.0 [1.1-8.0]) with chronic pain significantly increasing the odds of any mental health care in the past year in adults older than 60 years of age. CONCLUSIONS Chronic pain increases the likelihood of mental health service use among older adults. Chronic pain may facilitate the presentation of distress in medical settings for these adults.

Effect of medicare part D benzodiazepine exclusion on psychotropic use in benzodiazepine users.

To evaluate the effect of the Medicare benzodiazepine coverage exclusion on psychotropic use of benzodiazepine users.

Medicare Part D Benzodiazepine Exclusion and Use of Psychotropic Medication by Patients With New Anxiety Disorders

OBJECTIVE The Medicare Modernization Act (MMA) specifically excluded benzodiazepines from Medicare Part D coverage starting in 2006; however, benzodiazepines are an effective, low-cost treatment for anxiety. This study evaluated the effect of the Medicare Part D benzodiazepine coverage exclusion among patients with new anxiety disorders. METHODS The authors used a quasi-experimental cohort design to study patients with new anxiety diagnoses from a large national health plan during the first six months of 2005, 2006, and 2007. Logistic and zero-truncated negative-binomial regression models using covered claims for behavioral, medical, and pharmaceutical care linked with eligibility files were used to estimate utilization and costs of psychotropic medication and health care utilization among elderly Medicare Advantage enrollees (N=8,397) subject to the MMA benzodiazepine exclusion and a comparison group of near-elderly (ages 60–64) enrollees (N=1,657) of a managed care plan. RESULTS Medicare Advantage enrollees diagnosed in 2005 had significantly (p<.05) higher rates of covered claims for benzodiazepines and all psychotropic drugs, lower rates of covered claims for nonbenzodiazepines, and lower expenditures for psychotropic drugs than enrollees diagnosed in 2006 and 2007. There were no significant differences over time in utilization or expenditures related to psychotropic medication among the comparison group. There also were no significant changes over time in outpatient visits for behavioral care by either cohort. CONCLUSIONS Among elderly patients with new anxiety diagnoses, the MMA benzodiazepine exclusion increased use of nonbenzodiazepine psychotropic drugs without substitution of increased behavioral care. Overall, the exclusion was associated with a modest increase in covered claims for psychotropic medication.

Do parent perceptions predict continuity of publicly funded care for attention-deficit/hyperactivity disorder?

OBJECTIVE: To examine whether parent perceptions about care (barriers, disorder knowledge, treatment willingness) vary among children who drop out of or stay in publicly funded care for attention-deficit/hyperactivity disorder (ADHD) and to explore whether parent perceptions are predictive of staying in care over time. METHODS: A longitudinal cohort study of 529 children ages 5 to 11 years receiving care for ADHD in primary care or specialty mental health clinics in a large, countywide, managed-care Medicaid program. Multiple logistic regression analyses were performed to identify parent perceptions associated with the likelihood of staying in care across three 6-month time intervals, controlling for child and parent demographic characteristics, parental distress, clinical need, and recent special education use. RESULTS: At least three-fourths of children had at least 1 contact for any mental health care during a 6-month time interval (75%, 85%, 76%). Parent-perceived barriers, ADHD knowledge, and counseling willingness did not predict staying in care, whereas willingness for medication treatment was predictive at baseline. Minority status, nonmarried parent, parental distress, clinical need, and special education use were predictive of staying in care, but mostly during only one 6-month time interval, and their influence varied over time. CONCLUSIONS: Parent willingness for medication treatment along with several demographic and need factors predicted staying in care but not consistently over time. Future research is needed to develop practical tools for clinicians to elicit parent priorities about ADHD treatment and to integrate them into quality-improvement interventions targeted to improving shared decision-making for longer term ADHD care.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors

OBJECTIVE The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients. METHODS In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use. RESULTS For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients. CONCLUSIONS Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

A Community-Partnered, Participatory, Cluster-Randomized Study of Depression Care Quality Improvement: Three-Year Outcomes

OBJECTIVE Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 93 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) for implementing depression quality improvement in underserved communities. CEP was more effective than RS in improving mental health-related quality of life, reducing behavioral health hospitalizations, and shifting services toward community-based programs at six months. At 12 months, continued evidence of improvement was found. This study examined three-year outcomes. METHODS Among 1,004 participants with depression who were eligible for three-year follow-up, 600 participants from 89 programs completed surveys. Multiple regression analyses estimated intervention effects on poor mental health-related quality of life and depression, physical health-related quality of life, behavioral health hospital nights, and use of services. RESULTS At three years, no differences were found in the effects of CEP versus RS on depression or mental health-related quality of life, but CEP had modest effects in improving physical health-related quality of life and reducing behavioral health hospital nights, and CEP participants had more social- and community-sector depression visits and greater use of mood stabilizers. Sensitivity analyses with longitudinal modeling reproduced these findings but found no significant differences between groups in change from baseline to three years. CONCLUSIONS At three years, CEP and RS did not have differential effects on primary mental health outcomes, but CEP participants had modest improvements in physical health and fewer behavioral health hospital nights.

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the programs quality-improvement efforts.