PubMed Health⌕ Search

Biomedical subjects

Robin E Clark

Publications and source records attributed to Robin E Clark.

10 recordsLinked to original sources
PubMed2006

Estimated payments to employment service providers for persons with mental illness in the Ticket to Work program.

OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.

Adolescent↗
PubMed2004

The Hartford study of supported employment for persons with severe mental illness.

The authors compared 3 approaches to vocational rehabilitation for severe mental illness (SMI): the individual placement and support (IPS) model of supported employment, a psychosocial rehabilitation (PSR) program, and standard services. Two hundred four unemployed clients (46% African American, 30% Latino) with SMI were randomly assigned to IPS, PSR, or standard services and followed for 2 years. Clients in IPS had significantly better employment outcomes than clients in PSR and standard services, including more competitive work (73.9% vs. 18.2% vs. 27.5%, respectively) and any paid work (73.9% vs. 34.8% vs. 53.6%, respectively). There were few differences in nonvocational outcomes between programs. IPS is a more effective model than PSR or standard brokered vocational services for improving employment outcomes in clients with SMI.

Adult↗
PubMed2004

Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants.

OBJECTIVE: There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing. METHODS: We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2,800000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice. RESULTS: With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was 10,321463 dollars, 5,743905 dollars, and 9,191352 dollars respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, 202,300671 dollars, 112,580535 dollars, and 180,150494 dollars. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of 46,179465 dollars for the cohort would result with strategy 2, if the incidence of kernicterus is high (1:10,000 births or higher) and the RRR is high (> or =0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from 4,145676 dollars to as high as 77,650240 dollars. CONCLUSIONS: Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.

Bilirubin↗
PubMed2004

Benzodiazepine prescription practices and substance abuse in persons with severe mental illness.

BACKGROUND: Benzodiazepines have many benefits for persons with severe mental disorders, but they may also lead to or exacerbate substance abuse. An American Psychiatric Association taskforce established practice guidelines in 1990 to assist physicians in managing these and other potential side effects of benzodiazepine use. The objectives of this study were to determine the prevalence of benzodiazepine use among persons with psychiatric disorders and to evaluate compliance with published prescribing guidelines. METHOD: We studied benzodiazepine use among New Hampshire Medicaid beneficiaries aged 18 to 64 years with ICD-9 diagnoses that were grouped under the headings "schizophrenia," "bipolar disorder," "major depression," and "other psychiatric disorders" from Jan. 1995 through Dec. 1999. Rates and length of use, frequency of high-potency/fast-acting prescriptions, and diazepam-equivalent dosages were compared for those with and without retrospectively determined evidence of substance abuse, substance dependence, or a procedure code indicating treatment for a substance use disorder (SUD). RESULTS: Five-year prevalence of benzodiazepine use for persons with and without SUD was 63% versus 54% for schizophrenia, 75% versus 58% for bipolar disorder, 66% versus 49% for major depression, and 48% versus 40% for other psychiatric disorders. Differences were statistically significant over 5 years and in 1999 (p <.0001). Among persons with major depression or other psychiatric disorders, those with comorbid SUD were more likely to use fast-acting/high-potency benzodiazepines; there were no such differences for those with schizophrenia or bipolar disorder. Persons with bipolar disorder or other psychiatric disorders and SUD received significantly higher diazepam-equivalent dosages than did those without SUD. CONCLUSION: Contrary to published guidelines, rates of benzodiazepine use are higher among Medicaid beneficiaries with severe mental illness and co-occurring SUD than among persons with severe mental illness alone. Additional research and possibly a reassessment of prescribing guidelines are recommended.

Adolescent↗
PubMed2003

Prescribing patterns for patients with posttraumatic stress disorder.

OBJECTIVE: The little information available about prescribing patterns for persons with posttraumatic stress disorder comes from male combat-veteran populations treated through programs of the Department of Veterans Affairs. The objective of this study was to comprehensively evaluate prescribing patterns for persons with a diagnosis of posttraumatic stress disorder (PTSD) in a community-based nonveteran sample in which women were well represented. METHODS: Prescription claims paid in December 1999 for New Hampshire Medicaid recipients with diagnostic codes for PTSD were analyzed. Frequencies of prescriptions for categories of medication were compared between patients with PTSD (N=165) and patients with major depression alone (N=2,208) and those with major depression co-occurring with PTSD (N=171). RESULTS: The patients with PTSD were predominantly women who were receiving services at community mental health centers. Selective serotonin reuptake inhibitors were more frequently prescribed for major depression (32 percent of cases) than for PTSD (23 percent). Other novel antidepressants were more frequently prescribed for major depression co-occurring with PTSD (25 percent of cases) than for major depression alone (18 percent). Atypical antipsychotic medications were more frequently prescribed for PTSD (17 percent of cases) and for major depression co-occurring with PTSD (20 percent) than for major depression alone (9 percent). Benzodiazepines and related hypnotics, trazodone, and mood stabilizers were more frequently prescribed for major depression co-occurring with PTSD than for major depression alone. CONCLUSIONS: The findings suggest that many outpatients who have PTSD are treated aggressively with medication, particularly when PTSD co-occurs with major depression, and that there are discrepancies between actual prescribing patterns and prescribing guidelines. These findings overlap trends observed in veteran populations.

Adult↗
PubMed2002

Recent trends in antipsychotic combination therapy of schizophrenia and schizoaffective disorder: implications for state mental health policy.

Little is known about antipsychotic combination therapy, although this practice is becoming increasingly common in the treatment of schizophrenia. Medicaid pharmaceutical claims for a cohort of 836 New Hampshire beneficiaries with schizophrenia or schizoaffective disorder were followed from 1995 through 1999. Use of traditional and atypical antipsychotic medications, antidepressants, anxiolytic hypnotics, and mood stabilizers was tracked monthly. The number of medications, frequency of coprescription, and Medicaid pharmaceutical costs are described. The proportion of individuals with schizophrenia and schizoaffective disorder treated with atypical antipsychotics grew from 43 percent in 1995 to 70 percent in 1999. At the same time, concurrent use of two or more antipsychotic medications quadrupled, increasing from 5.7 percent to 24.3 percent. Persons with schizophrenia were also prescribed more antidepressants (increased from 18.5% in 1995 to 35.6% in 1999), anxiolytics (increased from 19.9% to 33.5%), and mood stabilizers (increased from 17.7% to 30.0%). The increase in multiple agent therapy appears to be broad-based. Data are needed on the effectiveness and cost-effectiveness of these practices to inform clinical decision making and health policy.

Adult↗
PubMedDate not supplied

Psychosocial treatment in the 21st century.

Over the past 50 years, psychosocial treatment has played an increasingly prominent role in helping persons with mental illness live in communities rather than in institutions. This paper briefly reviews evidence for and discusses three forms of treatment-assertive community treatment, supported employment, and cognitive behavior treatment-which have been studied extensively and are widely accepted as effective interventions. Forces are discussed that have shaped these and other psychosocial treatment over the past five decades. Despite the accumulated evidence, many questions remain about the cost-effectiveness and applicability of these treatments in specific populations and service environments. The development of these and other treatments has been, and continues to be, shaped by concerns about rising health care costs, a heightened emphasis on evidence-based treatment and by consumers taking a more active role in determining the services, and outcomes that are most helpful to them.

Cost-Benefit Analysis↗
PubMedDate not supplied

Medicare and medicaid costs for schizophrenia patients by age cohort compared with costs for depression, dementia, and medically ill patients.

OBJECTIVE: The authors describe per-capita Medicaid and Medicare expenditures across age cohorts for individuals with schizophrenia and compare expenditures for patients with schizophrenia and those with depression, dementia, and non-psychiatric medical disorders. METHODS: Medicaid and Medicare claims were identified for dually-eligible beneficiaries ages 19+ in New Hampshire during 1999 (schizophrenia: N=1,423; depression: N=2,219; dementia: N=1,942; medical disorders alone: N=4,260). Annual per-capita weighted average expenditures were calculated for inpatient, outpatient, home-health, nursing home, pharmacy, physician, and other services. RESULTS: The greatest per-capita expenditures for individuals with schizophrenia were among older beneficiaries ($39,154 for ages 65-74 and $43,461 for ages 75+), versus younger beneficiaries ($25,633 for ages 19-44 and $31,529 for ages 45-64). Outpatient services were the highest expenditure among younger adults (ages 19-64), whereas nursing home services were the highest expenditure for ages 65+. Total expenditures for individuals with schizophrenia exceeded those for individuals with depression, dementia, or medical disorders across all age cohorts except age 45-64, where dementia expenditures were highest. Among individuals age 65-74, per-capita expenditures for schizophrenia were $11,304 higher than for depression and $28,256 higher than for medical disorders. CONCLUSION: Schizophrenia is one of the most expensive disorders across the adult lifespan, and expenditures increase across age cohorts. Effective interventions are needed that improve independent functioning in older age, in conjunction with innovative models of home- and community-based services that decrease high use of and expenditures for nursing homes.

Adult↗
PubMedDate not supplied

The Medical Home Index: development and validation of a new practice-level measure of implementation of the Medical Home model.

OBJECTIVE: The Medical Home is a clinical practice concept that sets new standards for pediatric primary care. This study describes the development and validation of a tool to measure the Medical Home. METHODOLOGY: The Medical Home Index (MHI) consists of 25 themes arranged among 6 domains of primary care office activity. A national panel of experts on the Medical Home reviewed a prototype of the instrument. Pediatric primary care offices completed the MHI and participated in 90-minute on-site interviews with two of the authors (J.W.M., K.S.). The study examined interrater reliability between the 2 project staff and between the practices and project staff and the internal consistency of MHI domains and themes. RESULTS: On a 100-point scale, 43 practices demonstrated a range of MHI summary scores from 18.9 to 75.4, with a mean of 43.9. Kappa coefficients of interrater reliability between two Center for Medical Home Improvement project staff were above.50 for all 25 themes. Kappa scores comparing each staff member and the practice sites' self-assessment found 80% of the themes at.65 or better for one interviewer (J.W.M.) and 60% of the themes at.65 or better for the second interviewer (K.S.). Intraclass correlation coefficients between the summary scores of the interviewers were.98 and between the scores of the two interviewers and the scores of the practices was.97. The internal consistency reliability standardized alpha coefficients across the 6 domains of the MHI ranged from.81 to.91, and the overall standardized alpha coefficient was.96. CONCLUSIONS: In the sample of practices studied, the MHI was an internally consistent instrument with acceptable reliability and validity for pediatric primary care practices to assess their implementation of the Medical Home concept. Further work is needed to study its correlation with other process and outcome measures and its performance in a wider range of practices.

Child↗