Michael D. Stein

Use of the ED as a Regular Source of Care: Associated Factors Beyond Lack of Health Insurance

STUDY OBJECTIVE To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care. METHODS We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED. RESULTS Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than

Prevalence and predictors of unmet need for supportive services among HIV-infected persons: impact of case management.

30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a

Reproductive Health Care and Family Planning Needs Among Incarcerated Women

25 copayment were in effect. CONCLUSION Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

Perceived needs and unmet needs for formal services among people with HIV disease

BACKGROUND Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood. OBJECTIVES To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons. RESEARCH DESIGN National probability sample. PARTICIPANTS A total of 2,832 HIV-infected adults receiving care. MEASURES Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services. RESULTS Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home healthcare (OR =0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need. CONCLUSIONS Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.

Trazodone For Sleep Disturbance After Alcohol Detoxification: A Double-Blind, Placebo-Controlled Trial

OBJECTIVES Women in correctional institutions have substantial reproductive health problems, yet they are underserved in receipt of reproductive health care. We assessed the level of risk for sexually transmitted diseases (STDs) and the reproductive health needs of 484 incarcerated women in Rhode Island to plan an intervention for women returning to the community. METHODS We used a 45-minute survey to assess medical histories, pregnancy and birth control use histories, current pregnancy intentions, substance use during the past 3 months, histories of childhood sexual abuse, and health attitudes and behaviors. RESULTS Participants had extremely high risks for STDs and pregnancy, which was characterized by inconsistent birth control (66.5%) and condom use (80.4%), multiple partners (38%), and a high prevalence of unplanned pregnancies (83.6%) and STDs (49%). Only 15.4% said it was not likely that they would have sexual relations with a man within 6 months after release. CONCLUSION Reproductive health services must be offered to incarcerated women. Such interventions will benefit the women, the criminal justice systems, and the communities to which the women will return.

Do mechanisms that link addiction treatment patients to primary care influence subsequent utilization of emergency and hospital care

This study presents estimates of the prevalence of perceived needs and unmet needs among people with HIV disease in the United States for six areas of community services: mental health, drug treatment, home care, housing, transportation, and entitlements. The prevalence of service needs and unmet needs within racial, gender, drug use history, and other subgroups was also examined. The study is based on a nonrandom cross-sectional sample of 907 people with HIV disease interviewed between November 1988 and May 1989 in nine major urban areas of the United States.Respondents reported high levels of need and unmet need across a variety of service areas. One third or more of all respondents reported a need for mental health services (57%), housing (39%), entitlements (34%), and transportation (32%). Within each of the six service areas, 40% or more reported unmet need. Women, people of color, and injected drug users were more likely to report unmet service need in a number of areas. Given the limitations of the sampling and the focus oncurrent needs, these estimates may represent a lower bound on the magnitude of service need and unmet need within this population.

Evolution of depressive symptoms in human immunodeficiency virus-infected patients entering primary care

BACKGROUND Trazodone is a commonly prescribed off-label for sleep disturbance in alcohol-dependent patients, but its safety and efficacy for this indication is unknown. METHODS We conducted a randomized, double-blind, placebo-control trial of low-dose trazodone (50 to 150 mg at bedtime) for 12 weeks among 173 alcohol detoxification patients who reported current sleep disturbance on a validated measure of sleep quality or during prior periods of abstinence. Primary outcomes were the proportion of days abstinent and drinks per drinking day over 6-months; sleep quality was also assessed. RESULTS Urn randomization balanced baseline features among the 88 subjects who received trazodone and 85 who received placebo. The trazodone group experienced less improvement in the proportion of days abstinent during administration of study medication (mean change between baseline and 3 months: -0.12; 95% CI: -0.15 to -0.09), and an increase in the number of drinks per drinking day on cessation of the study medication (mean change between baseline and 6 months, 4.6; 95% CI: 2.1 to 7.1). Trazodone was associated with improved sleep quality during its administration (mean change on the Pittsburgh Sleep Quality Index between baseline and 3 months: -3.02; 95% CI: -3.38 to -2.67), but after it was stopped sleep quality equalized with placebo. CONCLUSIONS Trazodone, despite a short-term benefit on sleep quality, might impede improvements in alcohol consumption in the postdetoxification period and lead to increased drinking when stopped. Until further studies have established benefits and safety, routine initiation of trazodone for sleep disturbance cannot be recommended with confidence during the period after detoxification from alcoholism.

Cognitive behavioural therapy for adherence and depression in patients with HIV: a three-arm randomised controlled trial

Background:Patients with drug use disorders are heavy users of emergency department (ED) and inpatient hospital care. This study examines whether formal mechanisms to link addiction treatment patients to primary medical care, either directly on site or by off-site referral—when compared with an absence of said mechanisms—might reduce these patients’ use of ED and hospital services after substance abuse treatment. Methods:We used longitudinal data from 6 methadone maintenance programs with 232 patients, 24 outpatient nonmethadone programs with 1202 patients, and 14 long-term residential programs with 679 patients in the National Treatment Improvement Evaluation Study. Multivariate logistic models controlling for health status and medical service utilization before treatment examined whether provision of medical services on- or off-site during treatment linkage led to reduced use of ED and hospital services in the year after treatment compared with no such provision. Results:On-site delivery of primary care reduced subsequent ED and hospital use among patients in methadone maintenance and long-term residential compared with the nonlinkage condition but not in outpatient nonmethadone programs. Off-site referral for medical care reduced subsequent ED visits but not hospitalizations in long-term residential programs. Conclusions:These findings suggest that for some treatment modalities, stronger primary care linkage mechanisms decrease subsequent utilization of expensive ED and hospital services. Future study should examine the cost implications of these strong linkage mechanisms and ways to strengthen linkages to off-site medical care.

Persistence on a stress-challenge task before initiating buprenorphine treatment was associated with successful transition from opioid use to early abstinence.

Our purpose was to examine among HIV-infected patients a) characteristics associated with depressive symptoms at initial primary care presentation and b) factors associated with improvement in depressive symptoms. We interviewed HIV-infected patients at initial presentation and reassessed them 6 months later. At baseline and follow-up, we collected data on depressive symptoms (CES-D) and other characteristics. Using multiple linear regression, we examined associations between CES-D score and baseline variables. We used multiple logistic regression to examine factors associated with improvement in depressive symptoms. Seventy-one percent of the baseline sample (N = 203) scored above the threshold considered indicative of depression. At 6 months, 36% of the subjects who were followed improved in depressive symptoms. Higher baseline CES-D scores, improvements in HIV-related symptoms, and joining a support group were associated with improvement. Depressive symptoms in this urban HIV-infected population were highly prevalent. It is essential to screen, identify, and treat depression among patients entering care for HIV disease. Encouragement in joining support groups is a reasonable component of a strategy for addressing this common condition.

Coping and burden among informal HIV caregivers.

BACKGROUND Depression is highly prevalent in people with HIV and has consistently been associated with poor antiretroviral therapy (ART) adherence. Integrating cognitive behavioural therapy (CBT) for depression with adherence counselling using the Life-Steps approach (CBT-AD) has an emerging evidence base. The aim of this study was to test the efficacy of CBT-AD. METHODS In this three-arm randomised controlled trial in HIV-positive adults with depression, we compared CBT-AD with information and supportive psychotherapy plus adherence counselling using the Life-Steps approach (ISP-AD), and with enhanced treatment as usual (ETAU) including Life-Steps adherence counselling only. Participants were recruited from three sites in New England, USA (two hospital settings and one community health centre). Patients were randomly assigned (2:2:1) to receive CBT-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), ISP-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), or ETAU (one Life-Steps session and five assessment visits roughly every 2 weeks), randomisation was done with allocation software, in pairs, and stratified by three variables: study site, whether or not participants had been prescribed antidepressant medication, and whether or not participants had a history of injection drug use. The primary outcome was ART adherence at the end of treatment (4 month assessment) assessed via electronic pill caps (Medication Event Monitoring System [MEMS]) with correction for pocketed doses, analysed by intention to treat. FINDINGS Patients were recruited from Feb 26, 2009, to June 21, 2012. Patients who were assigned to CBT-AD (94 randomly assigned, 83 completed assessment) had greater improvements in adherence (estimated difference 1·00 percentage point per visit, 95% CI 0·34 to 1·66, p=0·003) and depression (Center for Epidemiological Studies depression [CESD] score estimated difference -0·41, -0·66 to -0·16, p=0·001; Montgomery-Asberg depression rating scale [MADRS] score -4·69, -8·09 to -1·28, p=0·007; clinical global impression [CGI] score -0·66, -1·11 to -0·21, p=0·005) than did patients who had ETAU (49 assigned, 46 completed assessment) after treatment (4 months). No significant differences in adherence were noted between CBT-AD and ISP-AD (97 assigned, 87 completed assessment). No study-related adverse events were reported. INTERPRETATION Integrating evidenced-based treatment for depression with evidenced-based adherence counselling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate effective psychosocial depression treatments such as CBT-AD to people living with HIV/AIDS and examine the cost-effectiveness of such approaches. FUNDING National Institute of Mental Health, National Institute of Allergy and Infectious Diseases.Summary Background Depression, highly prevalent in HIV, is consistently associated with worse ART adherence. Integrating CBT for depression with adherence counseling using the “Life-Steps” approach (CBT-AD) has an emerging evidence base. The aim of the current study was to test the efficacy of CBT-AD. Methods We conducted a three-arm RCT (N=240 HIV-positive adults with depression), comparing CBT-AD to Life-Steps integrated with information and supportive psychotherapy (ISP-AD) (both 12 sessions), and to ETAU (1 session Life-Steps). Participants were recruited from three sites in New England area, two being hospital settings, and one being a community health center. Randomization was done via a 2:2:1 ratio, using random allocation software by the data manager, in pairs, stratified by three variables: site, whether or not the participant was prescribed antidepressant medications, and history of injection drug use. The primary outcome was adherence assessed via electronic pill caps (MEMs) with correction for “pocketed” doses. Secondary outcomes included depression, plasma HIV RNA and CD4. Follow-ups occurred at 4, 8 and 12 months. We used intent-to treat analyses with ANCOVA for independent-assessor pre-post assessments of depression and mixed effects modeling for longitudinal assessments. Clinical Trial Registration: NCT00951028, https://clinicaltrials.gov/ct2/show/NCT00951028), closed to new participants. Findings The period of recruitment was February 26, 2009 to June 21, 2012, with the 12-month follow-up period extending until April 29, 2013. There were no study-related adverse events. CBT-AD (n=94 randomized, 83 retained) had greater improvements in adherence (Est.=1·00, CI=0·34, 1·66, p=0·003) and depression (CES-D Est.=−0·41, CI=−0·66, −0·16, p=0·001; MADRS Est.=−4·69, CI=−8·09, −1·28, p=0·007; CGI Est.=−0·66, CI=−1·11,-0·21, p=0·005) than ETAU (49 randomized, 46 retained) at post-treatment (4-month). Over follow-ups, CBT-AD (84 retained) maintained higher adherence (Est.=8·93, CI=1·90, 15·97, p=0·013) and lower depression on the CES-D (Est=−3·56, CI=−6·08, −1·05, p=·005) and CGI (Est.=−0·39, CI=−0·77, −0·18, p=·04) than ETAU (86 retained); however, not for the MADRS. There were no significant differences between CBT-AD and ISP-AD (97 randomized, 87 retained) for the post-treatment or follow-up (86 retained) analyses. There were no intervention effects on HIV RNA or CD4, though a higher percentage (91·4%) than expected was virally suppressed at baseline. Interpretation Integrating evidenced-based treatment for depression with evidenced-based adherence counseling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate of effective psychosocial depression treatments such as CBT-AD to individuals living with HIV/AIDS, as well as examine the cost-effectiveness of such approaches. Funding National Institute of Mental Health (R01MH084757) and some author time from NIAID 5P30AI060354, and P30AI042853.