Biomedical subjects

John C Fortney

Publications and source records attributed to John C Fortney.

17 recordsLinked to original sources

PubMed2006

Outpatient visit chaining among patients with serious mental illness.

BACKGROUND: To reduce travel burdens, patients may coordinate outpatient services to receive multiple encounters during a single day. Unmeasured visit "chaining" may bias estimates of the impact of accessibility barriers when utilization volume is measured using visit days. No studies have evaluated differential encounter chaining by distance. OBJECTIVES: We sought to evaluate the prevalence and predictors of visit chaining among patients with serious mental illnesses (SMIs), to evaluate whether patients living farther from providers are more likely to chain encounters, and to assess distance barriers using alternative measures of utilization volume. DATA SOURCES: We used the Veterans Affairs (VA) National Psychosis Registry, including Fiscal Year 2000 diagnosis and utilization data for 141,275 VA patients with SMI diagnoses. STUDY DESIGN: Random intercepts hierarchical regression to examine the relationship between distance to nearest VA provider and encounters/visit day, adjusting for age, gender, race/ethnicity, marital status, service-connection, previous hospitalization, and treatment setting and comorbidities at initial use. Negative binomial regressions to evaluate distance effects on visit day and encounter volume. Analyses adjusted for patient clustering within facilities. PRINCIPAL FINDINGS: With increased distance, patients had more encounters/visit day. Patients with bipolar disorder were more likely than patients with schizophrenia or other psychoses to chain treatments in association with greater distances. CONCLUSIONS: When utilization volume is measured in terms of visit days, analyses may overestimate distance barriers, because remote patients are more likely to chain encounters within visit days. However, distance remains a substantial barrier limiting total outpatient visit volume. Enhanced services coordination may reduce accessibility barriers for remote patients.

Adult↗

PubMed2006

Impact of comorbid anxiety disorders on health-related quality of life among patients with major depressive disorder.

OBJECTIVE: This study examined the impact of comorbid anxiety disorders-posttraumatic stress disorder (PTSD), generalized anxiety disorder, and panic disorder-on health-related quality of life among primary care patients enrolled in a collaborative care depression intervention study for the Department of Veterans Affairs (VA). METHODS: Baseline data were used from 324 participants in the Telemedicine Enhanced Antidepressant Management (TEAM) Study, a multisite randomized effectiveness trial targeting VA primary care patients with depression. Health-related quality of life was measured by using the Quality of Well-Being Scale, self-administered version (QWB-SA) and the mental component summary (MCS-12V) and physical component summary (PCS-12V) of the 12-item Short Form Health Survey for Veterans (SF-12V). RESULTS: A majority of participants (69 percent) had at least one anxiety disorder. Generalized anxiety disorder and PTSD predicted scores on the QWB-SA. PTSD predicted scores on the PCS-12V, but none of the comorbid anxiety disorders predicted scores on the MCS-12V. In addition, social support, depression severity, and the number of chronic medical conditions significantly predicted QWB-SA scores; the number of self-reported chronic physical health conditions and the number of depression episodes significantly predicted PCS-12V scores; and social support and depression severity significantly predicted MCS-12V scores. CONCLUSIONS: According to scores on the QWB-SA, generalized anxiety disorder and PTSD comorbid with major depressive disorder impair health-related quality of life above and beyond major depressive disorder alone.

Anxiety Disorders↗

PubMed2005

Are primary care services a substitute or complement for specialty and inpatient services?

OBJECTIVE: To determine whether strategies designed to increase members' use of primary care services result in decreases (substitution) or increases (complementation) in the use and cost of other types of health services. STUDY SETTING: Encounter and cost data were extracted from the Department of Veterans Affairs (VA) administrative data sources for the period 1995-1999. This timeframe captures the VA's natural experiment of increasing geographic access to primary care by establishing new satellite primary care clinics, known as Community-Based Outpatient Clinics (CBOCs). STUDY DESIGN: We exploited this natural experiment to estimate the substitutability of primary care for other health services and its impact on cost. Hypotheses were tested using ordinary least squares (OLS) regression, which was potentially subject to endogeneity bias. Endogeneity bias was assessed using a Hausman test. Endogeneity bias was accounted for by using instrumental variables analysis, which capitalized on the establishment of CBOCs to provide an exogenous identifier (change in travel distance to primary care). DATA COLLECTION: Demographic, encounter, and cost data were collected for all veterans using VA health services who resided in the catchment areas of new CBOCs and for a matched group of veterans residing outside CBOC catchment areas. PRINCIPAL FINDINGS: Change in distance to primary care was a significant and substantial predictor of change in primary care visits. OLS analyses indicated that an increase in primary care service use was associated with increases in the use of all specialty outpatient services and inpatient services, as well as increases in inpatient and outpatient costs. Hausman tests confirmed that OLS results for specialty mental health encounters and mental health admissions were unbiased, but that results for specialty medical encounters, physical health admissions, and outpatient costs were biased. Instrumental variables analyses indicated that an increase in primary care encounters was associated with a decrease in specialty medical encounters and was not associated with an increase in physical health admissions, or outpatient costs. CONCLUSIONS: Results provide evidence that health systems can implement strategies to encourage their members to use more primary care services without driving up physical health costs.

Adult↗

PubMed2005

The influence of comorbid chronic medical conditions on the adequacy of depression care for older Americans.

OBJECTIVES: To assess the effect of the co-occurrence of four common chronic medical conditions (hypertension, diabetes mellitus, arthritis, heart disease) on the probability of receiving adequate depression treatment. DESIGN: Retrospective analysis of the 2000 and 2001 Medical Expenditure Panel Surveys (MEPS). SETTING: Households in the United States. PARTICIPANTS: MEPS respondents aged 65 and older with self-reported depression (N=498). MEASUREMENTS: Adequate depression treatment is defined as receiving eight psychotherapy sessions or filling at least four antidepressant prescriptions at a minimally adequate dosage. Comorbid diabetes mellitus, hypertension, heart disease, and arthritis in older persons with depression were identified from patient self-report. RESULTS: An estimated 34% (95% confidence interval=28-39%) of older persons with self-reported depression received an adequate course of depression treatment during a calendar year. Having hypertension or diabetes mellitus was associated with significantly greater odds of receiving adequate depression care (hypertension odds ratio (OR)=1.81, P=.02; diabetes mellitus OR=1.77, P=.03). Having heart disease or arthritis was not significantly associated with the odds of receiving adequate depression care. CONCLUSION: Some chronic medical conditions are associated with a greater likelihood of receiving adequate depression care; comorbid medical conditions do not result in lower quality of depression treatment in older persons. The high prevalence rates of comorbid depression and low rates of adequate depression care in elderly persons with chronic illnesses point to the importance of improving primary care depression treatment or enhancing specialty mental health referral.

Aged↗

PubMed2005

Does improving geographic access to VA primary care services impact patients' patterns of utilization and costs?

The Department of Veterans Affairs (VA) has been establishing community-based outpatient clinics (CBOCs) across the country to improve veterans' access to and use of primary care services, thereby decreasing the need for costly specialty outpatient and inpatient care. Using a quasi-experimental, pre-post study design, we examined whether the establishment of CBOCs has affected access, use, and costs for VA patients residing in their catchment areas. Most patients residing in CBOC catchment areas did not receive care at CBOCs, resulting in only small increases in primary care utilization. While CBOCs improved veterans' access, they had little impact on overall patterns of utilization and cost.

Aged↗

PubMed2004

Relationship between perceived stigma and depression severity.

The purpose of this study was to explore the relationship between perceived stigma and being in treatment for depression and current depression severity. Face-to-face interviews were conducted with a convenience sample of depressed subjects from a Veterans Administration outpatient mental health clinic (N = 54) and never-depressed subjects from a Veterans Administration primary care clinic (N = 50). Depression severity was measured using the 9-item Primary Care Evaluation of Mental Disorders depression measure. Stigma was measured using the 5-item Stigma Scale for Receiving Psychological Help modified for depression treatment. Statistical analyses included Spearman correlation and multivariate regression. In the correlation analysis, being in treatment for depression compared with never experiencing depression was associated with significantly higher levels of perceived stigma (p <.001). In separate multivariate models controlling for significant univariate correlates, greater depression severity (p <.001) and meeting criteria for current major depression (p <.001) were significant predictors of perceived stigma. Greater depression severity appears to be a strong predictor of perceived stigma.

Cross-Sectional Studies↗

PubMed2004

Disparities in the adequacy of depression treatment in the United States.

OBJECTIVE: There is evidence of disparities in depression treatment by factors such as age, race or ethnicity, and type of insurance. The purpose of this study was to assess whether observed disparities in treatment are due to differences in rates of treatment initiation or to differences in the quality of treatment once treatment has been initiated. METHODS: Logistic regression models using data from the 2000 Medical Expenditure Panel Survey were estimated to assess the role of age, race or ethnicity, and type of insurance on rates of initiation of depression treatment for persons with self-reported depression and on rates of adequate treatment for those receiving treatment. RESULTS: African Americans and Latinos were significantly less likely to fill an antidepressant prescription than Caucasians. However, among patients who filled at least one prescription for an antidepressant, there were no racial or ethnic disparities in the probability of receiving an adequate trial of antidepressant medication. African Americans were more likely than Latinos and Caucasians to receive an adequate course of psychotherapy. Persons who did not have insurance coverage were less likely to initiate any depression treatment compared with those who did have insurance. However, if treatment was initiated, no difference in the probability of receiving adequate treatment was observed. Elderly persons were less likely to receive an adequate course of psychotherapy or counseling compared with younger persons. CONCLUSIONS: Disparities in depression treatment appear to be due mainly to differences in rates of initiation of depression treatment, given that rates of adequate care generally did not differ once treatment was initiated.

Adolescent↗

PubMed2003

Rural-urban differences in health care benefits of a community-based sample of at-risk drinkers.

CONTEXT: Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas. PURPOSE: This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas. METHODS: A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. FINDINGS: Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees. CONCLUSIONS: Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.

Actuarial Analysis↗

PubMed2003

Differences between physical and behavioral health benefits in the health plans of at-risk drinkers.

OBJECTIVE: The goal of this study was to describe the physical and behavioral health benefits of a representative community-based sample of at-risk drinkers potentially in need of behavioral health services. METHODS: A screening instrument for at-risk drinking was administered by telephone to a random community sample of more than 12,000 adults. A telephone interview was conducted with the health plans of 294 at-risk drinkers who were insured and who consented to the release of their insurance records to collect information about supply-side cost-containment strategies (for example, gatekeeping and restrictions on choice of provider), and demand-side cost-containment strategies (for example, deductibles, limits, coinsurance, and copayments). Information about health plan characteristics was successfully collected for 217 (72 percent) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. RESULTS: Both provider choice restrictions and gatekeeping were more likely to be used for behavioral health care than for physical health care. Greater cost-sharing for mental health than for physical health was most often achieved by using additional limits (83 percent) and higher coinsurance (66 percent) and less often achieved by using higher copayments (38 percent) and additional deductibles (13 percent). The greater cost-sharing for behavioral health amounted to a 30 percent ($42) difference in annual out-of-pocket costs for an average user of behavioral health services compared with full parity. CONCLUSIONS: The results provide information to advocacy groups and policy makers about how much equalization would have to occur in the insurance market before full parity could be achieved between physical health and behavioral health benefits for a population of individuals potentially in need of behavioral health services.

Adult↗

PubMed2002

Depressive disorders and alcohol dependence in a community population.

This cross-sectional study examines sociodemographic, clinical and func tional correlates of comorbid depression in a community sample of 268 individuals with alcohol dependence. Results of analyses comparing drinkers with either current or past depression to never-depressed drinkers showed that respondents in the former two groups were more likely to be female and report more comorbid drug use disorders. In addition to marked functional impairment for currently depressed drinkers, we also found that respondents with past depression were significantly less likely to have health insurance coverage. This lack of insurance for previously depressed persons calls for future work examining the potential influence of this barrier to access care on both clinical and functional outcomes.

Alcoholism↗

PubMed2002

Evaluation of the Department of Veterans Affairs community-based outpatient clinics.

OBJECTIVE: This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. SUBJECTS: There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. RESULTS: The details of the project's findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. CONCLUSION: CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: access and utilization performance measures.

OBJECTIVES: The purpose of this study was to compare access and utilization performance measures between Community-Based Outpatient Clinics (CBOC) and primary care clinics at parent VA Medical Centers (VAMC) and between VA-staff CBOCs and contract CBOCs. METHODS: The study design was cross-sectional and retrospective. Performance measures were based on data routinely collected for administrative and research purposes by the VA. The sample included all primary care patients (n = 37,084) treated at the 38 CBOCs opened before 4/1/98 (30 VA-staff and 8 contract) and all primary care patients (n = 318,369) treated at the 32 parent VAMCs. Six months of service use data were used to derive the access and utilization performance measures. Multivariate regression analyses were used to control for observable casemix differences. RESULTS: CBOCs are attracting new high priority patients to the VA health care system. CBOC patients had more primary care encounters and fewer specialty encounters than patients in the primary care clinics of the parent VAMCs. VA-staffed CBOC patients had more primary care encounters and fewer specialty encounters than contract CBOC patients. CONCLUSIONS: CBOCs are helping the VA achieve its goals of attracting new patients and shifting the focus of care from the specialty to the primary care setting.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: quality of care performance measures.

BACKGROUND: The Veterans Health Administration (VHA) recently initiated a system of Community-Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to compare quality of care provided to veterans at CBOCs and at traditional hospital-based VA Medical Center (VAMC) clinics. RESEARCH DESIGN: Quality of care was assessed using medical record data abstracted at CBOCs and VAMCs. The analysis used a logistic regression model that allowed for possible within-facility correlation and controlled for patient differences between facilities. SUBJECTS: The study included 4768 patients from 20 geographically diverse CBOCs and 2433 patients from the 20 VAMCs associated with these CBOCs. MEASURES: Quality of care was measured using 7 Prevention Index (PI) indicators and 9 Chronic Disease Care Index (CDCI) indicators, which assess compliance with nationally recognized guidelines for primary prevention, early disease detection, and care of patients with chronic disease. RESULTS: In the overall CBOC versus VAMC comparisons, performance was not significantly different on 15 of the 16 PI and CDCI indicators. In the comparisons between individual CBOCs and VAMCs pairs, 5 out of 20 CBOCs performed significantly below the affiliated VAMC on 4 or more indicators. CONCLUSIONS: These results suggest that CBOCs overall are providing a similar level of quality of care as VAMCs based on the PI and CDCI, although performance at several individual CBOCs fell below their affiliated VAMC on some indicators. Therefore, it appears that CBOCs are a valid approach for providing quality primary care to veterans.

Aged↗

PubMed2002

VA community-based outpatient clinics: performance measures based on patient perceptions of care.

BACKGROUND: The Department of Veterans Affairs (VA) recently initiated a system of Community- Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to determine the effect of CBOCs on patients' perceptions of care. RESEARCH DESIGN: The study design is a cross-sectional survey. SUBJECTS: This study compares 4,980 patients from 44 geographically diverse CBOCs to 4,159 patients from 36 parent VA Medical Center primary care clinics administratively and geographically associated with the CBOCs studied. MEASURES: Survey data were obtained from the 1998 VA National Outpatient Customer Satisfaction Survey which assesses eight multiitem scales addressing access and timeliness of care, education/information, patient preferences, emotional support, coordination of care, courtesy, and specialty care access. Each scale was evaluated based upon item responses that indicate a problem with care. The survey also contained SF-12 health status measures used for case-mix adjustment. RESULTS: Multivariate logistic regression controlling for patient health status measures revealed that CBOC patients reported fewer problems with care than VA-based patients on 7 of 8 scales though the absolute differences were small for most of the scales. The largest difference was observed for the access/timeliness scale. Significant differences between VA-staff and contract CBOCs were not observed. CONCLUSIONS: These results suggest that veterans participating in VA's initiative to provide primary care in community-based settings report no more than, and in some dimensions fewer problems with care compared with veterans who receive care in VAMC clinics.

Aged↗

PubMed2002

VA community-based outpatient clinics: cost performance measures.

OBJECTIVE: To examine the direct costs of treating veterans in Community-Based Outpatient Clinics (CBOC) and primary care clinics operated by VA medical centers (VAMCs) between April 1998 and September 1998. RESEARCH DESIGN: In a retrospective observational study of patients in eighteen CBOCs and fourteen VAMCs, direct costs were compared. In addition, the costs of treating patients in new and established CBOCs were also examined. MEASURES: The three types of costs examined include direct cost per primary care visit, direct primary care cost per patient, and total direct cost per patient in ordinary least squares regressions with facility-specific random effects. Indirect costs for overhead and administration were excluded. All cost comparisons controlled for patient characteristics and case-mix differences via the Diagnostic Cost Group methodology. RESULTS: Results indicate that CBOC patients and VAMC patients had similar direct primary care costs on a per visit and per patient basis. Total direct costs for CBOC patients were lower compared with VAMC patients, because of lower specialty and ancillary care costs. Patients in new CBOCs had similar primary, specialty, ancillary and inpatient care costs when compared with patients in established CBOCs. CONCLUSION: Lower total costs for CBOC patients may be a consequence of substituting primary care at CBOCs for expensive specialty and ancillary care at VAMCs. CBOCs may be an alternative approach to providing care to veterans at a lower cost than traditional delivery models based in VA Medical Centers.

Aged↗

PubMedDate not supplied

Design and implementation of the telemedicine-enhanced antidepressant management study.

OBJECTIVE: Evidence-based practices designed for large urban clinics are not necessarily transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because it is typically not feasible to employ on-site mental health specialists. The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to evaluate a collaborative care model adapted for small rural clinics using telemedicine technologies. The purpose of this paper is to describe the TEAM study design. METHOD: The TEAM study was conducted in small rural Veterans Administration community-based outpatient clinics with interactive video equipment available for mental health, but no on-site psychiatrists/psychologists. The study attempted to enroll all patients whose depression could be appropriately treated in primary care. RESULTS: The clinical characteristics of the 395 study participants differed significantly from most previous trials of collaborative care. At baseline, 41% were already receiving primary care depression treatment. Study participants averaged 5.5 chronic physical health illnesses and 56.5% had a comorbid anxiety disorder. Over half (57.2%) reported that pain impaired their functioning extremely or quite a bit. CONCLUSIONS: Despite small patient populations in rural clinics, enough patients with depression can be successfully enrolled to evaluate telemedicine-based collaborative care.

Ambulatory Care Facilities↗

PubMedDate not supplied

The triple threat for chronic disease: obesity, race, and depression.

The authors investigated the interrelationships between race, obesity, depression, and chronic disease by abstracting data from all primary-care patients seen at a family-medicine clinic over a 3-year period. A total of 8,197 patients were included in the analysis. Sixty-three percent of patients were either overweight (26%) or obese (37%). African-American race, obesity, and having a diagnosis of depression each independently and significantly increased the likelihood of having a chronic disease. Also, these risk factors interacted to create an increased likelihood of disease prevalence. Thus, obesity, race, and depression interacted to create a "triple threat" of developing certain chronic diseases.

Adult↗