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ABSTRACT: BACKGROUND AND OBJECTIVE: Medical groups have invested billions of dollars in electronic medical records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system. DATA SOURCES/SETTING: Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline. STUDY DESIGN: The United Kingdom Prospective Diabetes Study Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality-adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective. PRINCIPAL FINDINGS: Patients in the intervention group had significantly lowered A1c (0.26 percent, p = .014) relative to patients in the control arm. Intervention costs were $120 (SE = 45) per patient in the first year and $76 (SE = 45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE = 0.01) and increased lifetime costs by $112 (SE = 660), resulting in an incremental cost-effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two-way, and probabilistic sensitivity analyses. CONCLUSIONS: Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system.
Health Services Research 05/2012; · 2.16 Impact Factor
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ABSTRACT: Proposals to move toward reducing geographic differentials in health care spending have focused on patterns of spending in Medicare. We show in this article that when considering each state as a whole, there is almost no relationship between the level of spending for Medicare beneficiaries and that for other populations. In sharp contrast to these state-level results, there is a strong relationship between Medicare and Medicaid spending in comparing Hospital Referral Regions within each state. We suggest that the strong intrastate regional correlations demonstrate the importance of the supply of hospital beds, specialists, and other health care resources as determinants of use and spending. In contrast, the lack of correlation at the state level suggests that other factors, such as state-level poverty rates, influence use and spending at the state level, and that these other factors influence Medicare and non-Medicare use and spending differently. These findings demonstrate that it is important to broaden our analytic focus from Medicare beneficiaries to the larger population, and to consider the likely effects of changes in Medicare payment policy on the care received by other state residents.
Health Affairs 05/2012; 31(5):948-55. · 4.31 Impact Factor
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ABSTRACT: This study examined changes in service use associated with providing age-specific services for youths in their transitional years, ages 18–24.
A quasi-experimental, difference-in-difference design with propensity score weighting was used to compare mental health service utilization (use of outpatient, inpatient, emergency, and justice system services) among 931 youths enrolled in outpatient programs specifically for transition-age youths and 1,574 youths enrolled in standard adult outpatient programs in San Diego County, California, from July 2004 through December 2009.
Among youths enrolled in outpatient programs geared toward youths of transitional age, the mean number of annual outpatient mental health visits increased by 12.2 (p<.001) compared with youths enrolled in standard adult outpatient programs.
Compared with traditional adult outpatient mental health programs, age-specific programs were associated with an increased use of outpatient mental health services. Future research is needed to assess the effectiveness of age-specific programs for transition-age youths and how use of these programs relates to improved clinical, educational, and vocational outcomes over time.
Psychiatric services (Washington, D.C.) 03/2012; 63(6):592-6. · 2.81 Impact Factor
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ABSTRACT: This qualitative study assessed the needs for mental health and other services among transition-age youths who were receiving services in youth-specific programs.
Thirteen focus groups were conducted between June 2008 and January 2009. The purposefully sampled participants included transition-age youths age 18 to 24 who were receiving services in youth-specific programs (N=75, eight groups), parents of transition-age youths (N=14, two groups), and providers in the youth-specific programs (N=14, three groups). The qualitative analysis used an inductive approach in which investigators focused on generating themes and identifying relationships between themes. Through a process of repeated comparisons, the categories were further condensed into broad themes illustrating service needs.
Youths expressed needs for improved scheduling of services, stronger patient-provider relationships, and group therapies that address past experiences of violence, loss, and sexual abuse and that provide skills for developing and nurturing healthy relationships. Parents and providers expressed needs for increased community-based and peer-led services. Youths, parents, and providers all expressed needs for more housing options and for mentors with similar life experiences who could serve as role models, information brokers, and sources of social support for youths who were pursuing education and employment goals.
Findings from the focus groups suggest that there is room for improvement in the provision of services that are relevant to the current needs and life experiences of transition-age youths. Even within age-specific programs, improvements in services are needed to foster transitions to independence.
Psychiatric services (Washington, D.C.) 02/2012; 63(4):338-42. · 2.81 Impact Factor
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Diabetes care 11/2011; 34(11):2486-7. · 8.09 Impact Factor
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ABSTRACT: It is well known that Medicaid spending per beneficiary varies widely across states. However, less is known about the cause of this variation, or about whether increased spending is associated with better outcomes. In this article we describe and analyze sources of interstate variation in Medicaid spending over several years. We find substantial variations both in the volume of services and in prices. Overall, per capita spending in the ten highest-spending states was $1,650 above the average national per capita spending, of which $1,186, or 72 percent, was due to the volume of services delivered. Spending in the ten lowest-spending states was $1,161 below the national average, of which $672, or 58 percent, was due to volume. In the mid-Atlantic region, increased price and volume resulted in the most expensive care among regions, whereas reduced price and volume in the South Central region resulted in the least expensive care among regions. Understanding these variations in greater detail should help improve the quality and efficiency of care-a task that will become more important as Medicaid is greatly expanded under the Affordable Care Act of 2010.
Health Affairs 07/2011; 30(7):1316-24. · 4.31 Impact Factor
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ABSTRACT: The types of pharmacist-provided medication therapy management (MTM) services provided to patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the effects of MTM on medication adherence and patient outcomes have only recently begun to be studied. Although available studies suggest that patients receiving MTM services have better antiretroviral therapy (ART) adherence and outcomes, only 1 study has examined a large group of patients with HIV/AIDS, and none has examined adherence or outcomes for more than 1 year. A pilot program conducted by the California Department of Health Care Services (DHCS) and Medi-Cal (California's Medicaid program) provided an opportunity to examine ART adherence and outcomes in a large patient population receiving MTM services in community pharmacies over 3 years.
To examine an HIV/AIDS pharmacy MTM compensation pilot program over a 3-year period (2005- 2007) in a sample of Medi-Cal beneficiaries by describing the associations between use of pilot pharmacies and (a) adherence to ART regimens; (b) medication utilization, including number and type of ART medication regimens and use of contraindicated ART regimens; (c) occurrence of opportunistic infections; and (d) all-cause pharmacy and medical costs.
This was a cohort study examining Medi-Cal pharmacy and medical claims data (2005-2007) for patients with HIV/AIDS who were served by pilot pharmacies versus other (nonpilot) pharmacies. The study groups, pilot and nonpilot pharmacy patients with HIV/AIDS, consisted of Medi-Cal beneficiaries aged 18 years or older as of January 1, 2005, who were continuously enrolled from January 1, 2004, through December 31, 2007, and who received both a diagnosis of HIV/AIDS and at least 1 ART pharmacy claim during both the index period (2004) and the study period (January 1, 2005, through December 31, 2007). Pilot pharmacy patients were identified as having filled 50% or more of their ART prescriptions each year at 1 of the 10 pilot pharmacies. Patients for whom comprehensive medication data were not available, including those enrolled in managed care plans and/or Medicare, were excluded. Adherence was defined as a medication possession ratio (MPR) of 80%-120% and excess medication fills as MPR greater than 120%. Logistic regression was used to investigate the factors associated with adherence. Comparisons were made between groups using bivariate statistics (Pearson chi-square for categorical variables and t-tests for continuous variables). For comparisons of costs, generalized linear models were used including predictor variables for age, gender, and race/ethnicity. RESEARCH RESULTS: The study sample consisted of 2,234 patients meeting the study inclusion criteria. The proportion of study patients receiving the majority of their prescription medications (ART plus non-ART) at pilot pharmacies was 19.7% in 2005 and increased to 27.6% in 2006 and 28.1% in 2007. The demographic profile of pilot pharmacy patients was similar to that of patients receiving medications at nonpilot pharmacies, except that pilot pharmacies had a higher proportion of Latino patients (e.g., 19.7% vs. 14.9% in 2007, respectively, P = 0.006). A greater percentage of pilot than nonpilot pharmacy patients were adherent to their ART medication regimens (e.g., 2007: 69.4% vs. 47.3%, respectively, P < 0.001). After controlling for age, gender, and ethnicity/race in logistic regression analysis, use of a pilot pharmacy (odds ratio [OR] = 2.74, 95% CI = 2.44-3.10) was the most important factor associated with likelihood of adherence. Each year, pilot pharmacy patients were more likely than nonpilot pharmacy patients to remain on a single type of ART regimen (e.g., 2007: 71.7% vs. 49.1%, respectively, P < 0.001) and less likely to have excess fills (e.g., 2007: 12.9% vs. 35.5%, respectively, P < 0.001) and to use contraindicated regimens (e.g., 2007: 8.9% vs. 12.2%, respectively, P = 0.027). The percentages of patients experiencing opportunistic infections were similar between groups each year, approximately 35% (P = 0.809-0.945). In the generalized linear model analyses, the between-group differences in predicted mean (standard error [SE]) total health care costs per patient were not significantly different in any year (e.g., 2007: $38,983 [$1,023] vs. $38,856 [$633], respectively, P = 0.915). In each year, predicted non- ART medication costs were approximately 30%-40% greater in the pilot pharmacy than nonpilot pharmacy group (e.g., 2007: $10,815 [$538] vs. $8,190 [$252], respectively, P < 0.001); however, predicted expenditures for inpatient services were significantly lower (e.g., 2007: $3,083 [$293] vs. $5,186 [$300], respectively, P < 0.001). Payment from the DHCS Medi-Cal program for MTM services was approximately $1,000 per pilot pharmacy patient per year.
Over a 3-year period, patients at pilot pharmacies consistently had higher medication adherence rates, were more likely to remain on a single type of ART regimen throughout the year, had fewer excess fills, and used fewer contraindicated regimens than nonpilot pharmacy patients. There were no significant differences in mean total cost per patient per group, and the additional MTM services payment added less than 3% to the total cost.
Journal of managed care pharmacy: JMCP 04/2011; 17(3):213-23. · 2.25 Impact Factor
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ABSTRACT: Pharmacist-provided medication therapy management services (MTMS) have been shown to increase patient's adherence to medications, improve health outcomes and reduce overall medical costs. The purpose of this study was to describe a pilot programme that provided pharmacy-based MTMS for patients with HIV/AIDS in the state of California, USA.
Pharmacists from the 10 pilot pharmacies were surveyed using an online data collection tool. Information was collected to describe the types of MTMS offered, proportion of patients actively using specific MTMS, pharmacist beliefs regarding effect on patient outcomes and barriers to providing MTMS, ability to offer MTMS without pilot programme funding and specialized pharmacist or staff training.
Each responding pharmacy (7 of 10) varied in the number of HIV/AIDS patients served and prescription volume. All pharmacists had completed HIV/AIDS-related continuing education programmes, and some had other advanced training. The type of MTMS being offered varied at each pharmacy with 'individualized counselling by a pharmacist when overuse or underuse was detected' and 'refill reminders by telephone' being actively used by the largest proportion of patients. Most, but not all, pharmacists cited reimbursement as a barrier to MTMS provision. Pharmacists believed the MTMS they provide resulted in improved satisfaction (patient and provider), medication usage, therapeutics response and patient quality of life.
The type of MTMS offered, and proportion of patients actively using, varied among participating pilot pharmacies.
Journal of Evaluation in Clinical Practice 12/2010; 16(6):1142-6. · 1.23 Impact Factor
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ABSTRACT: Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.
Community Mental Health Journal 09/2010; 47(4):454-62. · 1.03 Impact Factor
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Diabetes care 07/2010; 33(7):1695-7. · 8.09 Impact Factor
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ABSTRACT: Chronically homeless adults with severe mental illness are heavy users of costly inpatient and emergency psychiatric services. Full-service partnerships (FSPs) provide housing and engage clients in treatment.
To examine changes in recovery outcomes, mental health service use and costs, and quality of life associated with participation in FSPs.
A quasi-experimental, difference-in-difference design with a propensity score-matched control group was used to compare mental health service use and costs of FSP with public mental health services. Recovery outcomes were compared before and after services use, and quality of life was compared cross-sectionally.
San Diego County, California, from October 2005 through June 2008.
Two hundred nine FSP clients and 154 clients receiving public mental health services.
Recovery outcomes (housing, financial support, and employment), mental health service use (use of outpatient, inpatient, emergency, and justice system services), and mental health services and housing costs from the perspective of the public mental health system.
Among FSP participants, the mean number of days spent homeless per year declined 129 days from 191 to 62 days; the probability of receiving inpatient, emergency, and justice system services declined by 14, 32, and 17 percentage points, respectively; and outpatient mental health visits increased by 78 visits (P < .001 each). Outpatient costs increased by $9180; inpatient costs declined by $6882; emergency service costs declined by $1721; jail mental health services costs declined by $1641; and housing costs increased by $3180 (P < .003 each). Quality of life was greater among FSP clients than among homeless clients receiving services in outpatient programs.
Participation in an FSP was associated with substantial increases in outpatient services and days spent in housing. Reductions in costs of inpatient/emergency and justice system services offset 82% of the cost of the FSP.
Archives of general psychiatry 06/2010; 67(6):645-52. · 12.26 Impact Factor
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ABSTRACT: In earlier work we demonstrated that increases in the cost of health care accounted for the decline in insurance coverage from 1979 to 2002. Here we examine whether our model adequately accounts for observed changes in coverage though 2007, and we provide an estimate of the effects of the recession on the number of uninsured Americans through 2010. We project that the number will increase by at least 6.9 million. The estimate does not directly take into account the additional effects of job losses, which are likely to add millions more to the number of uninsured Americans.
Health Affairs 06/2009; 28(4):w573-7. · 4.31 Impact Factor
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ABSTRACT: We analyzed the impacts of nativity and mental health (MH) on work by gender for non-elderly adults using the 2002 National Survey on Drug Use and Health. We employed two indicators of MH - the K6 scale of Mental Illness (MI) and an indicator for symptoms of Mania or Delusions (M/D). Instrumental variable (IV) models used measures of social support as instruments for MI. Unadjusted work rates were higher for immigrants (vs US-born adults). Regressions show that MI is associated with lower rates of work among US-born males but not immigrant males and females; M/D is associated lower rates of work among US-born males and females, and among immigrant males. Results did not change using IV models for MI. Most persons with MI work, yet symptom severity reduces labor supply among natives especially. Immigrants' labor supply is less affected by MI.
Health Economics 04/2009; 19(4):396-421. · 2.12 Impact Factor
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ABSTRACT: This study examined mental health service utilization and costs associated with the California Assembly Bill 2034 housing-first program for homeless persons in San Diego County: Reaching Out and Engaging to Achieve Consumer Health (REACH).
Encounter data were used to identify REACH clients and a control group that was matched by propensity score. Mental health services costs for case management, outpatient services, inpatient and emergency services, criminal justice system services, and total services were summarized for two-year periods before and after clients initiated REACH. Incremental costs of the program were calculated as the difference in cost among clients in the REACH group, from pre- to postintervention, less the difference in cost among those in the control group from pre- to postintervention.
A total of 177 REACH clients and 161 clients in a control group matched by propensity score were identified. Among REACH participants, case management costs increased by $6,403 (p<.001) from pre- to postintervention, inpatient plus emergency services costs declined by $6,103 (p=.034), and costs for mental health services provided by the criminal justice system declined by $570 (p=.020) compared with the control group. The standardized difference-in-difference estimate of the total costs between REACH clients and the control group was not significant.
Participation in REACH was associated with substantial increases in outpatient services as well as cost offsets in inpatient and emergency services and criminal justice system services. The net cost of services, $417 over two years, was substantially lower than the total cost of services ($20,241).
Psychiatric services (Washington, D.C.) 04/2009; 60(4):445-50. · 2.81 Impact Factor
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ABSTRACT: The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications.
Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status.
Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients.
Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.
Psychiatric services (Washington, D.C.) 03/2009; 60(2):175-82. · 2.81 Impact Factor
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ABSTRACT: The advent of combined antiretroviral therapy (ART) has increased treatment effectiveness but created new challenges for patients infected with human immunodeficiency virus (HIV) and for community pharmacists managing patients' drug therapy. The ability of pharmacist-provided medication therapy management (MTM) services to increase medication adherence, improve health outcomes, and reduce overall medical costs has been demonstrated in community pharmacies for chronic diseases such as diabetes and hypertension. However, the effectiveness of pharmacist-provided MTM services in HIV/acquired immune deficiency syndrome (AIDS) has not been well studied. In January 2005, a pilot program to evaluate MTM services for patients with HIV/AIDS began in California, allowing 10 HIV/AIDS specialty pharmacies to receive compensation for the MTM services that they provided to HIV/AIDS patients.
To examine the first year of the HIV/AIDS pharmacy MTM compensation pilot program, which described and compared pilot and nonpilot pharmacies with respect to (a) patient characteristics; (b) intermediate outcomes including type and number of ART medication regimens used, rates of adherence and excess medication fills for ART, use of contraindicated ART regimens, and occurrence of opportunistic infections; and (c) pharmacy and medical costs.
This was a cohort study examining 2005 Medi-Cal pharmacy and medical claims data for patients with HIV/AIDS who were served by pilot pharmacies versus other pharmacies. The HIV/AIDS patients were Medi-Cal beneficiaries aged 18 years or older as of January 1, 2005, who were continuously enrolled from January 1, 2004, through December 31, 2005, and diagnosed with HIV/AIDS, identified by receipt of at least 1 ART prescription and at least 1 medical claim with a diagnosis (primary or secondary) of HIV/AIDS (ICD-9-CM code 042.0) during both the index period (the year before pilot program implementation, 2004) and the intervention period (the study year, 2005). The only difference in the inclusion criteria for the 2 cohorts was that the pilot pharmacy patients were required to have filled 50% or more of their antiretroviral prescriptions in 2005 at 1 of the 10 pilot pharmacies. Adherence was defined as a medication possession ratio (MPR) of 80%-120% and excess medication fills as MPR greater than 120%. Comparisons were made between groups using bivariate statistics (Pearson chi-square for categorical variables and t-tests for continuous variables). For comparisons of costs, generalized linear models assuming a gamma distribution and log link function were used; predictor variables for the models included age, gender, race/ethnicity, and dual coverage under Medicare.
A total of 7,018 HIV/AIDS patients in the Medi-Cal population were identified as meeting the study criteria. Of these, 19.3% (n=1,353) were pilot pharmacy patients. The demographic profile of pilot pharmacy patients was similar, but not identical, to that of patients receiving medications at other pharmacies. A larger percentage of pilot pharmacy patients were on protease inhibitor-based ART medication regimens (63.8% vs. 54.8%, P<0.001), remained on a single type of ART therapy throughout the study year (56.8% vs. 34.2%, P<0.001), and were classified as adherent (56.3% vs. 38.1%, P<0.001), compared with other pharmacy patients. Fewer pilot pharmacy patients used contraindicated regimens (11.6% vs. 16.6%, P<0.001) or had excess medication fills (19.7% vs. 44.8%, P<0.001). The rate of opportunistic infections did not differ significantly between groups (28.2% vs. 26.1%, P=0.121). The total mean (standard error) annual health care cost per patient was 10% higher in pilot pharmacies than in other pharmacies ($40,596 [$889] vs. $36,937 [$479], P=0.001); driven by use of (a) medications (primarily non-ART medications) and (b) mental health services. Payment from the California Department of Health Care Services for MTM services averaged $1,014 per pilot pharmacy study patient.
Study findings for the first year of the MTM program suggest that the pilot pharmacy patients received more appropriate HIV treatment. The degree to which these differences are affected by selfselection of patients into the pilot pharmacies is unknown. Longer-term outcomes and costs of the pilot program will be examined when data for subsequent years are available.
Journal of managed care pharmacy: JMCP 01/2009; 15(1):32-41. · 2.25 Impact Factor
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ABSTRACT: This study examined longitudinal trends in the use of mood stabilizers and antipsychotics for treatment of bipolar disorder in a large public mental health system and whether trends differed by age, gender, and race-ethnicity.
Data were from Medicaid beneficiaries with bipolar disorder receiving services in the San Diego County public mental health system from 2001 to 2004. For each year the proportion of clients receiving any pharmacotherapy and the proportion receiving antipsychotics alone, mood stabilizers alone, or antipsychotics plus mood stabilizers were determined. Pharmacotherapy use was examined by age, gender, and race-ethnicity.
A total of 1,473 clients were identified who were continuously enrolled in Medicaid during the four years. Seventy-five percent received mood stabilizers or antipsychotics. Of this group, 33% received antipsychotics alone, 23% mood stabilizers alone, and 44% both antipsychotics and mood stabilizers. The percentage receiving mood stabilizers or antipsychotics increased significantly, from 71% in 2001 to 77% in 2004, primarily because of increased use among women. Use of mood stabilizers alone declined from 25% to 20%, and use of antipsychotics alone increased from 32% to 36%. African Americans and Latinos were less likely than non-Latino whites to receive mood stabilizers or antipsychotics; this pattern was stable over time.
Antipsychotics were prescribed for a larger percentage of clients than mood stabilizers. Persons from ethnic minority groups were less likely to receive either medication type. Research is needed to examine factors affecting pharmacotherapy in bipolar disorder and mechanisms underlying racial-ethnic disparities in pharmacotherapy, including their persistence over time.
Psychiatric services (Washington, D.C.) 11/2008; 59(10):1169-74. · 2.81 Impact Factor
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ABSTRACT: Limited data are available on how older adults access public mental health systems. This study examines how uninsured or publicly insured older adults with severe mental illness in San Diego County initially accessed the public mental health system, as well as their subsequent use of public mental health services, as compared to younger adults.
Data from San Diego County, 2002-2006, were used to examine how older adults initially accessed the public mental health system, and their utilization over the subsequent 90 days. Multivariate regression models were used to control for demographic and clinical characteristics.
Older adults (age 60 +) were more likely to access the public mental health system through the Psychiatric Emergency Response Team (PERT), a combined law-enforcement and psychiatric service that responds to psychiatric related 911 calls. Older adults were also less likely to receive follow-up care. This lower rate of follow-up was due to both the initial site of service--and an associated lower rate of follow-up among PERT clients--as well as a lower rate of follow-up among older adult clients initiating services in other sectors.
This paper suggests two areas for intervention that would improve access to care for older adults: improving linkages and referrals between PERT and outpatient providers; and additional efforts to retain older adults at outpatient programs.
International Journal of Geriatric Psychiatry 10/2008; 24(3):313-8. · 2.42 Impact Factor
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ABSTRACT: To assess the feasibility and cost of integrating diabetes and depression care management in three community clinics serving a low-income and predominantly Spanish-speaking Latino population.
We screened diabetes patients for depression, and for those with depressive symptoms, we provided depression care management. We assessed changes in depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9), diabetes self-care activities (nutrition, exercise, and medication adherence), and costs.
Thirty-three percent of patients with diabetes had symptoms of major depression. Among 99 patients completing the study, PHQ-9 scores declined by an average of 7.5 points from 14.8 to 7.3 (P < 0.001). Clients averaged 6.7 visits with the care manager during the study period. Costs of depression care management were estimated to be $512 per participant.
Adding a depression care manager to an existing diabetes management team was effective at reducing depressive symptoms at a reasonable cost.
Diabetes care 07/2008; 31(7):1324-6. · 8.09 Impact Factor
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ABSTRACT: There is substantial interest in attempts to reduce the number of uninsured persons by providing subsidies to small businesses. To measure the responsiveness of small businesses to offers of subsidized coverage, the authors conducted a randomized controlled trial in which selected groups of San Diego businesses were offered the opportunity to purchase coverage at prices ranging from $20 to $100 per month for an employee-only policy. At $20 per month, an estimated 40% of eligible businesses purchased insurance; at $100 per month, 13% purchased insurance. Small businesses not currently offering insurance to employees are not very responsive to large reductions in the price of coverage. Programs to subsidize insurance for small businesses and their employees are unlikely to substantially reduce the number of uninsured persons.
Medical Care Research and Review 05/2008; 65(2):187-206. · 2.96 Impact Factor
