Biomedical subjects

Dennis Wallace

Publications and source records attributed to Dennis Wallace.

15 recordsLinked to original sources

PubMed2006

Long-term housing and work outcomes among treated cocaine-dependent homeless persons.

Communities across the United States have initiated plans to end chronic homelessness. In many of these communities, addiction treatment programs remain the default point of entry to housing and services. This study examined the percentage of cocaine-using homeless persons (all with psychiatric distress) attaining stable housing and employment 12 months after entering a randomized trial of intensive behavioral day treatment, plus one of the following for 6 months: no housing; housing contingent on drug abstinence; housing not contingent on abstinence. Of 138 participants, the percentages with stable housing and employment at 12 months were 34.1 and 33.3%, respectively. Analyses suggested superior outcomes in trial arms that offered housing as part of the behavioral treatment. The majority of participants, however, did not achieve housing or employment, in part because of the limited capacity of the local housing programs to accommodate persons who had not achieved perfect abstinence. The findings demonstrate a helpful role for addiction treatment and suggest the need for services to support housing of persons who reduce but do not eliminate all substance use.

Adult↗

PubMed2006

Substance abuse treatment and psychiatric comorbidity: do benefits spill over? Analysis of data from a prospective trial among cocaine-dependent homeless persons.

BACKGROUND: Comorbid psychiatric illness can undermine outcomes among homeless persons undergoing addiction treatment, and psychiatric specialty care is not always readily available. The prognosis for nonsubstance abuse psychiatric diagnoses among homeless persons receiving behaviorally-based addiction treatment, however, is little studied. RESULTS: Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996-1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid non-addiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p = 0.12). CONCLUSION: Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population.

Adult↗

PubMed2005

To house or not to house: the effects of providing housing to homeless substance abusers in treatment.

OBJECTIVES: Housing typically is not provided to homeless persons during drug abuse treatment. We examined how treatment outcomes were affected under 3 different housing provision conditions. METHODS: We studied 196 cocaine-dependent participants who received day treatment and no housing (NH), housing contingent on drug abstinence (ACH), or housing not contingent on abstinence (NACH). Drug use was monitored with urine testing. RESULTS: The ACH group had a higher prevalence of drug abstinence than the NACH group (after control for treatment attendance), which in turn had a higher prevalence than the NH group. All 3 groups showed significant improvement in maintaining employment and housing. CONCLUSIONS: The results of this and previous trials indicate that providing abstinence-contingent housing to homeless substance abusers in treatment is an efficacious, effective, and practical intervention. Programs to provide such housing should be considered in policy initiatives.

Adult↗

PubMed2004

Transitions during effective treatment for cocaine-abusing homeless persons: establishing abstinence, lapse, and relapse, and reestablishing abstinence.

Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the manner in which drug use changes as a result of abstinent-contingent housing and work.

Adult↗

PubMed2003

Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up.

Abstinence, employment, and homelessness treatment outcomes at 12-month follow-up are presented from a study comparing behavioral day treatment plus abstinence-contingent housing and work therapy with behavioral day treatment only among homeless persons who abuse crack cocaine. Within-group improvements were revealed, but group differences for drug abstinence found in J. B. Milby et al. (2000) failed to persist at 12 months. Drug use measurement and treatment termination explanations are discussed. Within- but not between-group differences were found for employment and homelessness outcomes at long-term follow-up. Research extending abstinence contingencies and continuous drug use monitoring is recommended. Questions about effectiveness of contingency management alone, role of coexisting psychiatric disorders on treatment outcome, and individualized treatment dosing are offered.

Adult↗

PubMed2003

Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons.

Substance use disorder diagnoses were used as a treatment outcome measure in a randomized comparison of day treatment (DT) and day treatment plus contingency management (DT+) among homeless persons with primarily crack/cocaine disorders. Participants (N = 127, DT+ = 69, DT = 58, 73.2% male, 82.7% African American) were assessed at baseline and 6-month treatment completion. Binary positive and negative diagnostic outcomes for cocaine, marijuana, and alcohol were compared by treatment group. DT+ was 2.1 times more likely to have a positive treatment outcome than DT. Concordance between diagnostic change and point and continuous abstinence outcomes were found. The use of diagnostic change can be a practical addition to drug toxicology and self-report treatment outcome measures for research and practice.

Adult↗

PubMed2003

Physical performance measures in the clinical setting.

OBJECTIVES: To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults. DESIGN: Prospective cohort study. SETTING: Primary care programs of a Medicare health maintenance organization (HMO) and Veterans Affairs (VA) system. PARTICIPANTS: Four hundred eighty-seven persons aged 65 and older. MEASUREMENTS: Lower extremity performance Established Population for Epidemiologic Studies of the Elderly (EPESE) battery including gait speed, chair stands, and tandem balance tests; demographics; health care use; health status; functional status; probability of repeated admission scale (Pra); and primary physician's hospitalization risk estimate. RESULTS: Veterans had poorer health and higher use than HMO members. Gait speed alone and the EPESE battery predicted hospitalization; 41% (21/51) of slow walkers (gait speed <0.6 m/s) were hospitalized at least once, compared with 26% (70/266) of intermediate walkers (0.6-1.0 m/s) and 11% (15/136) of fast walkers (>1.0 m/s) (P <.0001). The relationship was stronger in the HMO than in the VA. Both performance measures remained independent predictors after accounting for Pra. The EPESE battery was superior to gait speed when both Pra and primary physician's risk estimate were included. Both performance measures predicted decline in function and health status in both health systems. Performance measures, alone or in combination with self-report measures, were more able to predict outcomes than self-report alone. CONCLUSION: Gait speed and a physical performance battery are brief, quantitative estimates of future risk for hospitalization and decline in health and function in clinical populations of older adults. Physical performance measures might serve as easily accessible "vital signs" to screen older adults in clinical settings.

Aged↗

PubMed2003

Particle concentrations in inner-city homes of children with asthma: the effect of smoking, cooking, and outdoor pollution.

Inner-city children have high rates of asthma. Exposures to particles, including allergens, may cause or exacerbate asthma symptoms. As part of an epidemiologic study of inner-city children with asthma, continuous (10-min average) measurements of particle concentrations were made for 2-week periods in 294 homes drawn from seven cities. Measurements were made using an optical scattering device that is most sensitive to fine particles. The concentrations recorded by these devices were corrected to agree with colocated outdoor gravimetric PM2.5 monitors. Indoor concentrations in the homes averaged 27.7 (standard deviation = 35.9) micro g/m3, compared with concurrent outdoor concentrations of 13.6 (7.5) micro g/m3. A multivariate model indicated that outdoor particles penetrated indoors with an efficiency of 0.48 and were therefore responsible for only 25% of the mean indoor concentration. The major indoor source was smoking, which elevated indoor concentrations by 37 micro g/m3 in the 101 homes with smokers. Other significant sources included frying, smoky cooking events, use of incense, and apartment housing, although the increases due to these events ranged only from 3 to 6 micro g/m3. The 10-min averaging time allowed calculation of an average diurnal variation, showing large increases in the evening due to smoking and smaller increases at meal times due to cooking. Most of the observed variance in indoor concentrations was day to day, with roughly similar contributions to the variance from visit to visit and home to home within a city and only a small contribution made by variance among cities. The small variation among cities and the similarity across cities of the observed indoor air particle distributions suggest that sources of indoor concentrations do not vary considerably from one city to the next, and thus that simple models can predict indoor air concentrations in cities having only outdoor measurements.

Air Pollutants↗

PubMed2002

Comparison of the responsiveness of the Barthel Index and the motor component of the Functional Independence Measure in stroke: the impact of using different methods for measuring responsiveness.

Two disability measures frequently used to assess the effects of interventions on stroke recovery are the Barthel Index (BI) and the motor component of the Functional Independence Measure (FIM Instrument). This study compared multiple measures of responsiveness of these instruments to stroke recovery between 1 and 3 months. Data on a 1- to 3-month change in the Instruments were obtained for 372 subjects who improved or maintained function on the modified Rankin Scale (MRS), using a subset of 459 eligible patients with confirmed stroke as defined by WHO criteria recruited from 12 participating hospitals in the Greater Kansas City area. Subjects were excluded because of death, early withdrawal from the study, missing MRS, or outcome data (57) decline on MRS (26), or inability to improve on MRS (4). Techniques used to assess responsiveness were: area under the ROC curve, Guyatt's effect size, paired t-statistics, standardized response mean, Kazis effect size, and mixed model adjusted t-statistic. The FIM Instrument and BI show little difference in responsiveness to change. The different responsiveness measures are generally consistent with this conclusion, with no measure clearly superior to the others. Large differences in the responsiveness measures were obtained within an instrument depending on the populations used (changers only or both changers and those who maintained function). Results also suggest responsiveness assessments are likely to be affected by time frame and phase of rehabilitation over which the responsiveness of a measure is determined.

Activities of Daily Living↗

PubMed2002

Co-morbidity adjustment for functional outcomes in community-dwelling older adults.

OBJECTIVE: To characterize relationships between self-reported co-morbidity and functional outcomes in community-dwelling older adults, and to assess whether the impact of co-morbidity persists even after adjustment for baseline functional status. DESIGN: Prospective observational study. We examined associations between self-reported co-morbidity at baseline and functional outcomes at one year, with and without adjustment for baseline functional status. SETTING: Outpatient clinics at a managed care and a Veterans Affairs site. SUBJECTS: Four hundred and fifty-seven community-dwelling older adults representing a broad spectrum of overall health status. MAIN OUTCOME MEASURES: (a) New basic ADL (activities of daily living) problem during follow-up; (b) 10-point decline in the physical function index of the MOS-36 (MOS-PFI). RESULTS: Co-morbidity was associated with adverse functional outcomes in bivariable analyses. After adjustment for age and baseline functional status, an accumulated co-morbidity score provided additional explanatory power for predicting new ADL problems; odds ratios were 2.30 (1.09, 5.09) and 2.96 (1.48, 6.25) for 2 and > or = 3 affected co-morbidity domains, respectively. The impact of baseline status was also important; odds ratios for new ADL problems were 4.77 (2.68, 8.81) when at least one instrumental activity of daily living (IADL) problem was present at baseline, and 15.6 (8.05, 31.3) when at least one basic ADL problem was present at baseline. CONCLUSIONS: Accumulated self-reported co-morbidity has significant negative effects on function at one year; these effects are attenuated but not eliminated by adjustment for baseline status. Co-morbidity adjustment is probably an important design element in clinical research focused on functional outcomes in older adults.

Activities of Daily Living↗

PubMed2002

Spirituality Index of Well-Being Scale: development and testing of a new measure.

OBJECTIVE: To evaluate the reliability and validity of the Spirituality Index of Well-Being (SIWB) Scale in a patient population. STUDY DESIGN: Cross-sectional survey. POPULATION: Community-dwelling elderly individuals (n = 277) recruited from primary care clinic sites in the Kansas City metropolitan area. OUTCOMES MEASURED: Internal consistency, concurrent construct validity, discriminant validity, and factor analysis with Varivax rotation. RESULTS: The initial version of the SIWB contained 40 items: 20 from a self-efficacy domain and 20 from a life scheme domain. Factor analysis yielded 6 items loaded most strongly on factor 1 (intrapersonal self-efficacy) and 6 other items loaded strongly on factor 2 (life scheme). The Self-efficacy subscale had an alpha of.83 and the Life Scheme subscale had an alpha of.80; the total 12-item SIWB Scale had an alpha of.87. The SIWB had significant and expected correlations with other quality-of-life measures related to subjective well-being: EuroQol (r =.18), Geriatric Depression Scale (r = -35), the Physical Functioning Index from the Short Form 36 (r =.28), and the Years of Healthy Life Scale (r = -.35). Religiosity did not correlated significantly with the SIWB (r =.12, P =.056). CONCLUSIONS: The 12-item SIWB Scale is a valid and reliable measure of subjective well-being in an older patient population.

Age Factors↗

PubMed2002

Costs and effectiveness of substance abuse treatments for homeless persons.

BACKGROUND: Several reviews of the effectiveness of drug abuse treatment have concluded that treatment works. However, studies analyzing cost-effectiveness or cost-benefits of drug treatment have been limited. Consequently, policy decisions regarding substance abuse treatment have utilized educated guesses or consensus of experts in the absence of controlled and scientifically rigorous studies of the benefits and costs of treatment. AIMS OF THE STUDY: This study presents a cost analysis of two randomized controlled studies comparing four drug addiction interventions for homeless persons. The studies controlled for some limitations of previous research in this area including random assignment. Findings are based on treatment costs obtained from actual expenditures and treatment outcomes of drug abstinence from toxicology tests. Cost-effectiveness is considered from the viewpoint of the treatment program. Cost-effectiveness from a societal viewpoint is discussed, but not calculated. METHODS: This is a retrospective analysis of treatment and treatment outcome costs from two randomized controlled drug addiction treatment outcome studies: Homeless 1 and Homeless 2. Both studies were two-group-usual versus enhanced-care designs with similar treatment components, outcome variables and assessment points, but different research questions. Both studies investigated the efficacy of a contingency management intervention specifically designed for persons who are homeless. This costs analysis reports direct costs of treatment by service category and costs of abstinence at 2-, 6-, and 12-month points by study and study treatment group. Treatment costs and costs per week abstinent are reported for four substance abuse treatments across two studies for persons homeless and addicted primarily to crack cocaine. Treatment components for each program included counseling, housing, work, administrative, and other expenses. RESULTS: Drug abstinence rates by treatment program for each study revealed superior outcomes for the enhanced interventions with the greatest abstinence found at the earlier time points (up to 6 months) as established by previous research. Abstinence rates at 12 months failed to differentiate treatment groups. Average costs per abstinent week were generally greater for the enhanced programs compared to usual care, except early in treatment where these were similar. The incremental direct cost ratios (in year 2000 dollars) for these enhanced programs to increase abstinence by one average week were similar ($1,244 and $1,007) for the Homeless 1 and 2 projects at 12-months. These figures are compared to figures of other life saving events. DISCUSSION: When only the direct costs of programs and their abstinence rates are considered, treatments that involve abstinent contingent work and housing have incremental cost ratios that are within the range of many other common social and medical interventions. These enhanced programs are more cost effective earlier in treatment than at 12-month follow-up due to relapse common among existing drug treatment. A methodological limitation of this study is that direct program costs do not measure the societal value of reducing homelessness itself. IMPLICATIONS FOR HEALTH POLICIES: Usual and improved treatment methods offer a cost-effective approach to improving abstinence among addicted homeless persons. Policy makers might reasonably choose to implement enhanced treatment programs that also reduce homelessness because the incremental cost of these programs is within a reasonable range compared to other common societal interventions. IMPLICATIONS FOR FURTHER RESEARCH: Methods and data need to be developed to better measure the societal benefit to communities of reducing the numbers of homeless persons with addictive drug problems.

Adult↗

PubMedDate not supplied

Urban-rural patterns of increasing antidepressant use among nursing facility residents.

OBJECTIVE: To characterize changing patterns of antidepressant use in nursing facilities across the urban-rural continuum during the mid-1990s. DESIGN: Retrospective analysis of antidepressant drug codes and demographic/clinical data from the Minimum Data Set (MDS) 1994 to 1997. SETTING: Kansas nursing facilities. PARTICIPANTS: Facility residents aged 65 and older. MEASUREMENTS: We examined (1) admission use and (2) after-admission use for newer and older antidepressants for each year separately, using a 4-stratum system to classify nursing facility location by county, from urban to most rural. Incidence rate ratios were determined for antidepressant use in each stratum using the urban strata as the reference. RESULTS: Remarkable increases in use of newer antidepressants were seen over time in all strata, but use was highest in the urban area. Modest urban-rural gradient effects attenuated over time and were not consistently seen across analyses and years. Tricyclic antidepressant (TCA) use remained largely unchanged over time and at much lower rates than newer agents. However, TCA use was also modestly higher in urban areas. Differences were clearer for use after admission, in contrast with admission use patterns. CONCLUSIONS: Newer antidepressants were rapidly adopted across the urban-rural continuum from 1994 to 1997. Marked increases in both admission and after-admission use of newer antidepressants were seen. Both newer and older antidepressants were used at modestly higher rates in urban areas. Further work is needed to elucidate the patient, prescriber, and facility factors that explain these prescribing patterns.

Aged↗

PubMedDate not supplied

Comparison of desipramine or carbamazepine to placebo for crack cocaine-dependent patients.

The authors compared the effects of desipramine or carbamazepine to placebo in an intensive outpatient program for cocaine abuse. Subjects recruited from an urban drug treatment program were randomly assigned to a double-blind, placebo-controlled, eight-week trial of desipramine, carbamazepine, or placebo. Patient ratings, urine drug screens, and blood samples were obtained weekly. Using survival analysis, the three groups did not differ in time to drop out of treatment. While subjects improved over time on all self-ratings related to cocaine use, mood, and craving, only two items related to mood were significantly different over time as a function of treatment group. Subjects in the two treated groups reported significantly more improvement on self-ratings of depression and irritability. No treatment differences were noted for sustained abstinence or for proportion of positive urine drug screens. Desipramine subjects who attained a minimum blood level were retained in treatment significantly longer than placebo or other non-compliant treatment groups. This finding supports previous reports of a possible role for desipramine in cocaine abuse treatment.

Adult↗

PubMedDate not supplied

Urban-rural differences in amitriptyline use among nursing facility residents.

OBJECTIVE: To characterize patterns of amitriptyline use across the urban-rural continuum. DESIGN: Retrospective analysis of antidepressant drug codes and demographic and clinical data from the Minimum Data Set (MDS), 1994 to 1997. SETTING: Kansas nursing facilities. PARTICIPANTS: Facility residents aged 65 and older. MEASURES: A four-strata system was used to classify nursing facility location by county, from urban to frontier. We examined admission use and after-admission use of amitriptyline across strata for each year separately. Unadjusted and adjusted odds ratios were determined for each stratum, using the urban stratum as the point of reference. RESULTS: Admission use of amitriptyline occurred in 2.3 to 4% of all admissions, and although such use was highest in the most rural stratum, no clear urban-rural gradient was found. In contrast, amitriptyline use 30 days or more after admission demonstrated modest urban-rural gradients in unadjusted and adjusted analyses. In 1997, when adjusted for demographic factors, odds ratios for amitriptyline use were 2.10 (1.54-2.87), 1.68 (1.33-2.13), and 1.49 (1.17-1.90) for the Frontier, Rural, and Densely Settled Rural categories as compared with the Urban reference group. CONCLUSIONS: After admission to Kansas nursing facilities, rural practice patterns for amitriptyline use are less favorable than those in urban areas, and an urban-rural gradient is identified. Further work is needed to identify explanatory patient, facility, and prescriber factors.

Journal Article↗