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Biomedical subjects

B M Astrachan

Publications and source records attributed to B M Astrachan.

At least 19 recordsLinked to original sources
PubMed1999

Prediction of treatment outcomes: lifetime depression versus the continuum of care.

We sought to determine the impact of a lifetime diagnosis of major depression on addiction treatment outcome. Structured interviews were conducted upon admission, and consecutive structured interviews were conducted prospectively for treatment outcome at 6 and 12 month follow-up periods. A multisite evaluation study of patients undergoing addiction treatment for alcohol and drug dependence was conducted in private outpatient facilities. Two thousand twenty-nine subjects from 33 independent programs were enrolled in a national registry for addiction treatment outcomes. The patients received abstinence-based addiction treatment with referral to a 12-step recovery program, often Alcoholics Anonymous, and continuing care in the treatment programs. The outcome areas measured were treatment completion, posttreatment substance use, exposure to psychosocial relapse risk factors, involvement with continuing care (formal aftercare and peer support groups), and posttreatment vocational functioning, health care utilization, and legal involvement. The prevalence rate of depressive symptoms over at least a 2-week period (major depression) in our sample was 28%. Multivariate analysis with stepwise multiple regression indicated that the most powerful predictors (relatively) of posttreatment alcohol/drug use were peer support group attendance and program continuing care involvement. Lifetime depression by itself and in interaction with each of these factors accounted for less than 2% of the variance in outcome. Logistic regression yielded similar results in the prediction of abstinence versus relapse. Posttreatment more than pretreatment factors appear to be more decisive in predicting risk for relapse.

Adult↗
PubMed1997

Lifetime diagnosis of major depression as a multivariate predictor of treatment outcome for inpatients with substance use disorders from abstinence-based programs.

A multisite, longitudinal study of patients undergoing inpatient alcohol and drug dependence treatment was conducted in private inpatient facilities, consisting of 4339 subjects from 38 independent programs enrolled in a national addiction treatment outcomes registry. Structured interviews were conducted upon admission, including documentation of current alcohol/drug disorder (DSM-III-R) and lifetime diagnosis of major depressive syndrome; structured interviews were conducted prospectively at 6- and 12-month follow-up periods. The prevalence rate of lifetime diagnosis of major depression in the sample was 39%. Comorbidity varied according to gender and substance of choice. Lifetime depressive symptoms did not correlate with differential length-of-stay, treatment completion, or follow-up consent and, at best, were very weakly associated with follow-up contact. Patients diagnosed with lifetime depression showed the same frequency of participation in posttreatment continuing care: they also showed statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates pre- vs. posttreatment comparable to those of patients without lifetime depression diagnosis. Lifetime major depressive syndrome was not a predictor of outcome in response to abstinence-based treatment. Involvement in posttreatment continuing care accounted for far greater outcome variance. Posttreatment vs. pretreatment factors may be more decisive in influencing risk for relapse.

Adolescent↗
PubMed1995

Issues and approaches in evaluating managed mental health care.

Data on the ways in which alternative forms of managed care affect the costs, quality, and outcomes of mental health are needed to inform health policy and clinical care decisions. Such evaluations, however, are difficult to implement for conceptual and practical reasons. The definition of managed mental health care is reviewed, alternative forms are described, and the activities and procedures that constitute managed care are identified. Examples from existing studies are used to describe the common roadblocks to implementing evaluations and to suggest methods for dealing with these barriers.

Cost-Benefit Analysis↗
PubMed1990

The impact of DRG-based budgeting on inpatient psychiatric care in Veterans Administration medical centers.

In 1985 the Veterans Administration (VA) implemented a prospective budgeting system for acute inpatient care based on diagnosis-related groups (DRGs). To assess the impact of this system on psychiatric care, this study reviewed data on all VA discharges for psychiatric or substance abuse disorders that occurred during the four years before and the four years after this system was implemented. During the four years following the implementation of DRG-based budgeting the number of annual discharges increased by 28.7% and the number of unique patients discharged increased by 15.5%. Average lengths of stay declined by 36.9% and total annual bed days of care per unique patient declined by 29.7%. These changes occurred in association with an 11.5% reduction in the total number of beds occupied by psychiatric patients, an 8.9% reduction in direct per diem expenditures for psychiatric care nationally, and a 32.7% decline in direct expenditures per episode, after adjustment is made for inflation. In spite of a continuing decline in the value of the available resources, largely due to the effect of inflation, prospective budgeting appears to have had a major impact on the pattern of inpatient psychiatric care in this large health care system.

Budgets↗
PubMed1989

Economics of practice and inpatient care.

The nature and structure of inpatient psychiatric services are rapidly evolving. This article identifies and explores how these changes are being influenced by four interrelated areas: rapid growth in general and private hospital psychiatric practice; increased connections of public, private, and voluntary sectors of care; the emergence and quick acceptance of capitated and managed care programs; and dramatic change and growth in the insurance industry. These four interrelated areas further the development of a two-tier system in psychiatry: one for those with insurance, and one of the poor and the severely disabled. The changes in these four areas have also led to greater demand for increased economic competition among services, and new alliances and innovations in the delivery of treatment. This article discusses how the four areas have combined to support a two-tier system and how they are likely to affect the future evolution of general and private hospital inpatient psychiatric practice.

Cost Control↗
PubMed1989

Medical practice in organized settings. Redefining medical autonomy.

Physicians are perplexed by the ongoing erosion of their individual professional autonomy. While the economic forces underlying such change have received much attention, the evolution of new organizational forms that modify and often diminish medical autonomy is less well understood. The practice of medicine is becoming more organized and more hierarchical. We emphasize the importance of organized medical groups, including the medical staff organization, as structures for appropriate peer monitoring, and for counterbalancing the burgeoning influence of governance and administrative constraints on practice. There is an ongoing tension within organizations between management, governance, and physicians. Over time one or another of these groups achieves some measure of dominance, but good management requires a balance of power. The role of the medical staff, which is poorly represented in some health care institutions and under threat in others, is considered. In general, we find that medical work is becoming more hierarchical, and that physician "leaders" do not substitute for collegial processes.

Institutional Practice↗
PubMed1988

The emergency department surveillance of alcohol intoxication after motor vehicle accidents.

To assess the surveillance of alcohol intoxication by surgical house staff, we examined the charts of 346 motor vehicle accident patients who presented to the trauma center of an urban teaching hospital emergency department. Half of the charts were reviewed before and half were reviewed after June 1986, when Connecticut enacted PA86-345, a law changing court rules of evidence so that the analysis by a hospital of a patient's blood could be used to establish probable cause for driving while under the influence of an intoxicant. We predicted and found no change in house-staff practice after passage of the law, since information about intoxication was obtained for immediate treatment. The rate of testing remained constant at 25%, with the median alcohol concentration at 200 mg/dL. Not one patient was referred for alcohol abuse evaluation or treatment. We recommend more vigorous attempts to evaluate, diagnose, and refer patients who abuse alcohol since they threaten the public health.

Accidents, Traffic↗
PubMed1987

Conceptual and methodological issues in the comparison of inpatient psychiatric facilities.

The authors compared the length of stay of acute admission patients at a mental health center and a nearby state hospital. The two facilities had significantly different length of stay distributions; the mean was not an adequate index to describe these patterns. Despite careful matching, patients at the state hospital were more disabled. Different patient characteristics were associated with length of stay at the two facilities, and these were also characteristics on which the patient populations differed at admission. The authors conclude that comparisons of hospitals, for example, on mean or median length of stay can be misleading unless the different functions, policies, and constraints of the facilities are taken into account.

Community Mental Health Centers↗
PubMed1984

Characterization of schizophrenic patients who commit suicide.

Twenty schizophrenic patients who committed suicide were compared with a randomly selected group and a sex-matched group of nonsuicidal schizophrenic patients and with a group of nonschizophrenic patients who committed suicide. The schizophrenic patients who committed suicide were more often men, and tended to be young, never married, non-Protestant, and white. They failed to communicate their suicidal intent directly, used highly lethal suicide methods, and tended not to have undergone stressful life events associated with their suicides. A thorough, case-by-case clinical assessment of potential suicidal ideation is essential with schizophrenic patients.

Adult↗
PubMed1984

The JCAH and psychiatry: current issues and implications for practice.

The Joint Commission on Accreditation of Hospitals recently revised its Accreditation Manual for Hospitals (AMH), used to assess the quality of care at health institutions. The authors briefly examine the history of accreditation of hospital-based psychiatric services. They then provide background on factors that influenced the revision of AMH standards such as third-party pressure for cost containment and consumer demands for high-quality health care. The authors also explore such issues as clinical privileges for nonphysician health professionals and the interdependence of the medical staff and the hospital administration in monitoring quality of care.

Accreditation↗
PubMed1984

Reevaluating the work of a community mental health center: the care of chronic patients.

Traditional forms of data-gathering have tended to underrepresent the care that community mental health centers provide to the more chronic, or seriously ill, patients. Using an alternative data-gathering method based on accumulated direct patient contacts, the authors illustrate how traditional data sets based on discharged patients and active patients yield very different views of the types of patients served and intensity of services received. Only by examining resource utilization among patients in both data sets were the authors able to show their center's extensive commitment to more chronic patients.

Anxiety Disorders↗
PubMed1981

A framework for the analysis of theoretical and therapeutic approaches to schizophrenia.

IN previous work we have begun to articulate a conception of psychiatry as a profession and to show how this conception may be useful in examining specific controversial issues such as national health insurance and the concept of prevention in psychiatry (Astrachan, Levinson, and Adler 1976; Adler, Levinson, and Astrachan 1978). We define a profession not in terms of its varied theories or forms of practice, but in terms of the major tasks it must perform and the perspectives it takes regarding these tasks. Historically, psychiatry has been committed to four major tasks. These interconnected tasks have been sanctioned by society, and all must be addressed if psychiatry is to retain its credibility and legitimacy. In practice, the tasks frequently are intertwined, yet they are conceptually distinct. In the present paper, we use this conception of psychiatry as a framework for the analysis of the many approaches that have been taken to the understanding and treatment of schizophrenia. Each task is defined in terms of a problematic condition to be controlled or eliminated: illness, defect, deviance, impeded growth. The rationale for work on each task is given by a corresponding theoretical perspective. There is marked disagreement, and often bitter controversy, about the validity of different theories, the value of different treatments, and even the legitimacy of various approaches. Let it be clear, then, that our goal is not to evaluate specific concepts and techniques, nor to argue that one task or perspective is more legitimate than any other. Our goal, rather, is to clarify the nature of the disagreement and to present a comprehensive framework within which different approaches to schizophrenia can be understood and compared and then reconnected in practice.

Antipsychotic Agents↗