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Biomedical subjects

Alexander S Young

Publications and source records attributed to Alexander S Young.

At least 19 recordsLinked to original sources
PubMed2007

Informatics systems to promote improved care for chronic illness: a literature review.

OBJECTIVE: To understand information systems components important in supporting team-based care of chronic illness through a literature search. DESIGN: Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness. MEASUREMENTS: The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated. RESULTS: In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

Chronic Disease↗
PubMed2007

The validity of using patient self-report to assess psychotic symptoms in schizophrenia.

Brief, reliable and valid measures of psychosis can be very useful in both clinical practice and research, and for identifying unmet treatment needs in persons with schizophrenia. This study examines the concurrent validity and receiver operating characteristics of the psychosis scale of the Revised Behavior and Symptom Identification Scale (BASIS-R). The study was conducted with 71 adults with schizophrenia who were randomly sampled from a large mental health clinic. Study participants at the West Los Angeles Veterans Healthcare Center were assessed using the BASIS-R, a subjective, self-report measure, and the UCLA Brief Psychiatric Rating Scale (BPRS), a clinician-rated measure administered by highly trained research staff. The psychosis scale of the BASIS-R shows good concurrent validity with the psychosis items on the BPRS. Using the BPRS as the gold standard for measuring psychosis, receiver operating characteristics suggest that both the weighted and unweighted versions of the BASIS-R psychosis scale adequately identify psychosis that is moderate or greater or severe. The performance of the two versions was similar. Unweighted scores are easier to calculate, and we therefore recommend cutoff scores based on the unweighted BASIS-R. We identified a cutoff score of 0.5 to best detect moderate or greater psychosis, and a cutoff score of 1.0 to best detect severe or extremely severe psychosis. The BASIS-R has potential as an assessment tool and screening instrument in schizophrenia.

Brief Psychiatric Rating Scale↗
PubMed2006

Co-location of health care for adults with serious mental illness and HIV infection.

This study describes persons with serious mental illness and comorbid HIV infection and examines the effect of co-location of mental health and HIV care on satisfaction, service utilization, and appropriateness of care. One hundred and eighteen subjects completed interviews and gave blood samples; medical records were abstracted. Most reported few barriers to care and satisfaction with mental health and HIV treatment. Co-location of mental health and HIV care did not influence satisfaction with care, utilization of services, or appropriateness of care. This report challenges the notion that persons with serious mental illnesses receive inadequate health care and that they have minimal capacity for illness management. These subjects may be benefiting from increased funding for, and attention to, persons with HIV infection.

Adolescent↗
PubMed2006

Behavioral health insurance parity for federal employees.

BACKGROUND: To improve insurance coverage of mental health and substance-abuse services, the Federal Employees Health Benefits (FEHB) Program offered mental health and substance-abuse benefits on a par with general medical benefits beginning in January 2001. The plans were encouraged to manage care. METHODS: We compared seven FEHB plans from 1999 through 2002 with a matched set of health plans that did not have benefits on a par with mental health and substance-abuse benefits (parity of mental health and substance-abuse benefits). Using a difference-in-differences analysis, we compared the claims patterns of matched pairs of FEHB and control plans by examining the rate of use, total spending, and out-of-pocket spending among users of mental health and substance-abuse services. RESULTS: The difference-in-differences analysis indicated that the observed increase in the rate of use of mental health and substance-abuse services after the implementation of the parity policy was due almost entirely to a general trend in increased use that was observed in comparison health plans as well as FEHB plans. The implementation of parity was associated with a statistically significant increase in use in one plan (+0.78 percent, P<0.05) a significant decrease in use in one plan (-0.96 percent, P<0.05), and no significant difference in use in the other five plans (range, -0.38 percent to +0.23 percent; P>0.05 for each comparison). For beneficiaries who used mental health and substance-abuse services, spending attributable to the implementation of parity decreased significantly for three plans (range, -201.99 dollars to -68.97 dollars; P<0.05 for each comparison) and did not change significantly for four plans (range, -42.13 dollars to +27.11 dollars; P>0.05 for each comparison). The implementation of parity was associated with significant reductions in out-of-pocket spending in five of seven plans. CONCLUSIONS: When coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs.

Cost Sharing↗
PubMed2006

Toward the implementation of mental health consumer provider services.

Encouraged by the New Freedom Commission, mental health systems such as the Veteran Administration (VA) are now becoming more recovery-oriented. Consumer providers (CPs)--those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems--are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed, and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.

Adult↗
PubMed2006

Patterns of HIV care for patients with serious mental illness.

Individuals with serious mental illness are at higher risk for HIV than are members of the general population. Although studies have shown that individuals with serious mental illness experience less adequate care and worse physical health outcomes than comparable patients without serious mental illness, little is known about HIV care among individuals with serious mental illness who become infected with HIV. In the present study, we describe patterns of highly active antiretroviral treatment (HAART) use and physician monitoring received by 154 patients with serious mental illness infected with HIV. Participants were recruited from mental health agencies in Los Angeles, California. Data from 762 HIV-only patients from a separate Western U.S. probability sample were used for comparison. High proportions of serious mental illness patients with HIV in our sample appeared to be receiving adequate HIV care. Fifty-one percent of all serious mental illness patients with serious mental illness with HIV were taking HAART, and the majority received close monitoring of their CD4 counts (84%) and viral loads (82%) throughout a 1-year period. HAART use and patterns of CD4 count and viral load monitoring did not differ significantly between patients with both serious mental illness and HIV, and patients with HIV only (all p > 0.05). Specialized programs providing assistance to serious mental illness populations with HIV may be helping to narrow health care disparities as a result of having serious mental illness.

Adult↗
PubMed2006

The impact of parity on major depression treatment quality in the Federal Employees' Health Benefits Program after parity implementation.

BACKGROUND: Since the 1990s, parity laws have been implemented to reduce inequities in mental health coverage compared with that for general medical conditions. It is unclear if parity under managed care is associated with improvements in mental health treatment quality. Major depressive disorder (MDD) is a prevalent but often undetected and undertreated and thus could potentially benefit from parity implementation. OBJECTIVE: The objective of this study was to examine the association between parity implementation and changes in MDD treatment quality in the Federal Employees' Health Benefits (FEHB) Program. METHODS: We conducted retrospective analyses of insurance claims data. Logistic regression models estimated quality changes for MDD-diagnosed enrollees from pre- to postparity. SUBJECTS: Subjects included MDD-diagnosed FEHB insured enrollees, aged 18-64, across multiple states and 6 FEHB plans before (1999-2000) and after (2001-2002) parity implementation. MEASURES: Measures included receipt of any antidepressant or psychotherapy within a given calendar year of diagnosis; receipt of appropriate psychotherapy frequency/intensity and duration; and pharmacotherapy duration during acute-phase treatment episodes. RESULTS: Postparity, several plans improved significantly in the likelihood of receiving antidepressant medication. In the acute-phase episodes, the greatest improvement was seen in the likelihood of follow up >or=4 months. Few or no other changes were observed in the acute-phase treatment intensity or duration quality measures. CONCLUSIONS: Parity under managed care was associated with modest improvements. The observed improvements were consistent with secular trends in MDD treatment. Whereas mental health parity is an important policy goal, these results highlight its limitations: improving the financing of care may not be sufficient to improve quality.

Adolescent↗
PubMed2005

Characteristics of individuals with severe mental illness who use emergency services.

Emergency services are both a safety net and a locus for acute treatment. While the population with severe, persistent mental illness uses emergency services at a high rate, few studies have systematically examined the causes of this service use. This study examines a random sample of 179 people who were high uti- lizers of services from the Los Angeles County Department of Mental Health. Interviews were conducted and 5 years of service use data were studied. Greater use of emergency services was associated with male gender, minority race, severe illness, homelessness, and less family support. Efforts to reduce emergency services need to improve access to appropriate community services, particularly for people who are homeless or lack family support.

Adult↗
PubMed2005

Needs for services reported by adults with severe mental illness and HIV.

This study examined the needs of people with severe mental illness and HIV. Results were based on interviews and CD4 counts of 294 individuals who received services from the Los Angeles County or the New York City public mental health system. Common unmet needs included financial assistance, housing, and mental health care. Thirty percent of the participants reported that they had at least one basic need that was not being met. Unmet need was less common as HIV infection advanced and was similar in frequency to that found in the general population with HIV. People with severe mental illness and HIV may be benefiting from the special resources that are available for people with HIV.

Adult↗
PubMed2005

Use of a consumer-led intervention to improve provider competencies.

OBJECTIVE: Client-centered care is a major aim of health care. In mental health, new client-centered treatment approaches that emphasize recovery, rehabilitation, and empowerment can improve outcomes for people with severe and persistent mental illness. However, these approaches are not widely used, in part because many clinicians lack the necessary competencies. The objective of this study was to evaluate the effectiveness of an innovative, consumer-led intervention, Staff Supporting Skills for Self-Help, which was designed to improve provider quality, empower mental health consumers, and promote mutual support. METHODS: The study was conducted at five large community mental health provider organizations in two western states. One organization in each state received the intervention. The intervention included education, clinician-client dialogues, ongoing technical assistance, and support of self-help. It focused on client-centered care, rehabilitation, and recovery. A one-year controlled trial evaluated the effect of the intervention on clinicians' competencies, care processes, and the formation of mutual support groups. Outcomes were assessed by using competency assessment survey instruments and semistructured interviews with clinicians and managers. RESULTS: A total of 269 clinicians participated in the study: 151 in the intervention group and 118 in the control group. Compared with clinicians at the control organizations, clinicians at intervention organizations showed significantly greater improvement in education about care, rehabilitation methods, natural supports, holistic approaches, teamwork, overall competency, and recovery orientation. CONCLUSIONS: A feasible, consumer-led intervention improves provider competencies in domains that are necessary for the provision of high-quality care.

Arizona↗
PubMed2005

Clinical utility of magnetic resonance imaging radiographs for suspected organic syndromes in adult psychiatry.

OBJECTIVE: In psychiatric practice, adult patients are most commonly referred for magnetic resonance imaging (MRI) to screen for suspected organic medical diseases of the central nervous system that can mimic psychiatric syndromes. We identified the most common signs and symptoms prompting MRIs to establish the predictive value of these signs and symptoms for clinically pertinent organic syndromes. METHOD: This study was a retrospective chart review of psychiatric patients at the Veterans Affairs Greater Los Angeles Health Care Center (Los Angeles, Calif.) who were referred for MRI of the brain between 1996 and 2002. Patients referred for evaluation of dementia were excluded. The specific indications leading clinicians to obtain MRI were identified and grouped. In order to offset the uncertain significance of many MRI findings, for this study, the predictive value of each indication was calculated based on the percentage of patients in whom clinical management changed in response to MRI findings rather than on the percentage with any abnormal MRI results. RESULTS: Of 253 patients who had MRIs, 38 (15%) incurred some degree of treatment modification as a result of MRI findings, including 6 patients in whom MRI identified a medical condition that became the focus of treatment. Six indications appeared most likely to prompt clinicians to obtain MRIs. Because pertinent results were associated with each of these indications, statistical evaluation did not reveal significant differences in their predictive values (chi(2) = 4.32, df = 5, p = .505). CONCLUSIONS: Unlike prior studies showing no value to screening radioimaging, this study shows MRI can be a useful screening test among patients suspected of having organic psychiatric disorders and that the common indications for MRI employed at one institution were predictive.

Adult↗
PubMed2004

A network-based system to improve care for schizophrenia: the Medical Informatics Network Tool (MINT).

The Medical Informatics Network Tool (MINT) is a software system that supports the management of care for chronic illness. It is designed to improve clinical information, facilitate teamwork, and allow management of health care quality. MINT includes a browser interface for entry and organization of data and preparation of real-time reports. It includes personal computer-based applications that interact with clinicians. MINT is being used in a project to improve the treatment of schizophrenia. At each patient visit, a nurse briefly assesses symptoms, side effects, and other key problems and enters this information into MINT. When the physician subsequently opens the patient's electronic medical record, a window appears with the assessment information, a messaging interface, and access to treatment guidelines. Clinicians and managers receive reports regarding the quality of patients' treatment. To date, MINT has been used with more than 165 patients and 29 psychiatrists and has supported practices that are consistent with improvements in the quality of care.

Decision Support Systems, Clinical↗
PubMed2004

Computer-assisted self-assessment in persons with severe mental illness.

BACKGROUND: It has been difficult to improve care for severe mental illness (SMI) in usual care settings because clinical information is not reliably and efficiently managed. Methods are needed for efficiently collecting this information to evaluate and improve health care quality. Audio computer-assisted self-interviewing (ACASI) can facilitate this data collection and has improved outcomes for a number of disorders, suggesting the need to test its accuracy and reliability in people with SMI. METHOD: Ninety patients with DSM-IV schizophrenia or schizoaffective disorder (N = 45) or bipolar disorder (N = 45) recruited between Oct. 15, 2002, and July 1, 2003, were randomly assigned to 1 of 2 study groups and completed 2 standardized symptom surveys (Revised Behavior and Symptom Identification Scale and the symptom severity scale of the Schizophrenia Outcomes Module 2) 20 minutes apart in a crossover study design. Half of the patients first completed the scales via an in-person interview, and the other half first completed the scales via an ACASI survey self-administered through an Internet browser using a touchscreen developed to meet the cognitive needs of people with SMI. We evaluated attitudes toward ACASI, understanding of the ACASI survey, internal consistency, correlations between the ACASI and interview modes, concurrent validity, and a possible administration mode bias. RESULTS: All ACASI and in-person interview scales had similar internal reliability, high correlations (r = 0.78-1.00), and mean scores similar enough as not to be different at p < .05. A large majority rated the ACASI survey as easier, more enjoyable, more preferable if monthly completion of a survey were required, and more private, and 97% to 99% perfectly answered questions about how to use it. CONCLUSION: ACASI data collection is reliable among people with bipolar disorder and schizophrenia and could be a valuable tool to improve their care.

Adult↗
PubMed2003

An instrument to assess competencies of providers treating severe mental illness.

One approach to improving the quality of care for severe mental illnesses (SMI) such as schizophrenia is through the improvement of provider competencies; the attitudes, knowledge, and skills needed to deliver high-quality care. This paper describes a new instrument designed to measure such a set of competencies. A total of 341 providers of services to clients with SMI at 38 clinics within 5 publicly financed treatment organizations in 2 western states were asked to complete a paper-and-pencil survey including the new Competency Assessment Instrument (CAI: 15 scales, each assessing a particular provider competency), and additional measures used to establish validity (Recovery Attitude Questionnaire--7, Client Optimism Scale). Seventy-nine percent (N = 269) responded at baseline, 83% (N = 282) responded at 2 weeks. Ninety-seven percent of baseline respondents completed the survey at 2 weeks. Most CAI scales have good internal consistency (Cronbach's alphas = .52-.93), test-retest reliability (scales ranged from .42 to .78), and validity, and should be useful in efforts to improve care.

Clinical Competence↗
PubMed2003

Does satisfaction reflect the technical quality of mental health care?

OBJECTIVE: To analyze the relationship between satisfaction and technical quality of care for common mental disorders. DATA SOURCE: A nationally representative telephone survey of 9,585 individuals conducted in 1997-1998. STUDY DESIGN: Using multinomial logistic regression techniques we investigated the association between a five-level measure of satisfaction with the mental health care available for personal or emotional problems and two quality indicators. The first measure, appropriate technical quality, was defined as use of either appropriate counseling or psychotropic medications during the prior year for a probable depressive or anxiety disorder. The second, active treatment, indicated whether the respondent had received treatment for a psychiatric disorder in the past year. Covariates included measures of physical and mental health and sociodemographic indicators. PRINCIPAL FINDINGS: Appropriate technical quality of care was significantly associated with higher levels of satisfaction. The strength of the association was moderate. CONCLUSIONS: Satisfaction is associated with technical quality of care. However, profiling quality of care with satisfaction will likely require large samples and case-mix adjustment, which may be more difficult for plans or provider groups to implement than measuring technical indicators. More importantly, satisfaction is not the same as technical quality, and our results suggest that at this time they cannot be made to approach each other closely enough to eliminate either.

Adult↗