PubMed Health⌕ Search

Biomedical subjects

Thomas P O'Toole

Publications and source records attributed to Thomas P O'Toole.

15 recordsLinked to original sources
PubMed2006

Physical health as a motivator for substance abuse treatment among medically ill adults: is it enough to keep them in treatment?

Substance-using adults often present at medical facilities for acute complications of their drug or alcohol use with transiently high motivation for addiction treatment. We studied a cohort of medically ill polysubstance-using adults admitted to a partial hospitalization/day-hospital program in an acute hospital, serially tracking their reasons for treatment motivation, pain and withdrawal scores, and readiness for change. Physical health concerns were the most frequently cited reason for wanting to enter substance abuse treatment at baseline (27.8%), yet individuals who cited this as their primary motivator were significantly less likely to complete the treatment program (14.8% vs. 40.7%, p = .03). However, 43% of respondents also recorded a shift in their motivation during treatment; 100% of those transitioning from an extrinsic motivator (e.g., physical health concerns) to an intrinsic motivator (e.g., wanting to do more with one's life) completed treatment, compared with only 38.4% of those whose extrinsic motivating factors were static. This suggests that medical illness represents a "treatable moment" to engage individuals in substance abuse treatment.

Acute Disease↗
PubMed2006

Does this patient really want treatment? Factors associated with baseline and evolving readiness for change among hospitalized substance using adults interested in treatment.

Little is known about motivation for treatment and readiness for change during an acute medical event. We present data from a cohort of 353 actively substance abusing adults assessed at baseline and every three days during their hospital admission for readiness to change substance use behaviors (URICA), self-reported motivations for substance abuse treatment, and pain and withdrawal symptoms. Factors independently associated with being in a higher (i.e., contemplation or action) stage of change included female sex (AOR=2.33; 95% CI: 1.42, 3.81), being on probation or parole (AOR=2.55; 95% CI: 1.32, 4.93), bipolar disorder (AOR 2.60; 95% CI: 1.20, 5.63), believing they would get sick again if drug use continued (AOR=2.24; 95% CI: 1.36, 3.70), being "tired of using" (AOR=2.91; 95% CI: 1.21, 6.96) and family concerns (AOR=1.78; 95% CI: 1.08, 2.96). During their hospitalization 43.6% increased from precontemplation or contemplation to a higher stage or remained in the action stage. Believing one would get sick again if substance use continued (AOR=2.42; 95% CI: 1.07, 5.48), physical health concerns (AOR=5.28; 95% CI: 1.36, 20.44) and citing "tired of using" as a primary motivator (AOR=2.88; 95% CI: 1.10, 7.54) were independently associated with increased stage of change.

Acute Disease↗
PubMed2006

Managing acutely ill substance-abusing patients in an integrated day hospital outpatient program: medical therapies, complications, and overall treatment outcomes.

BACKGROUND: Substance-abusing adults are admitted to hospitals for medical complications from their drug and alcohol use at substantially higher rates than the general public; yet, their care is often defined by against medical advice (AMA) discharges and low rates of referral to addiction treatment programs. METHODS: We present findings from a chart review of consecutive admissions to an integrated medical-substance abuse treatment program designed for acutely ill, hospitalized substance using adults. We specifically looked at factors associated with program completion and medical complications in this cohort of at-risk adults. RESULTS: Overall, 83 patient cases were studied. The mean age was 41.2 years; most were African American (73.5%), male (68.7%), and homeless (77.1%). Heroin (96.4%) and cocaine (88.0%), followed by alcohol (44.6%) were the most commonly used substances before admission. The most common admitting diagnoses were infectious endocarditis (43.4%), abscess or nonhealing ulcer (18.1%), and osteomyelitis (13.3%) with intravenous antibiotic (68.7%), physical therapy (48.2%), or wound care (41.0%), the most commonly prescribed care on the integrated care/day hospital unit. The mean length of stay in the day hospital was 12.4 days. Overall, 69.9% of patients successfully completed their medical therapy, and 63.9% were successfully referred to an outpatient substance abuse treatment program. Only 10.8% required an unscheduled hospital readmission and 15.7% required an after-hours emergency department visit during their stay. CONCLUSION: Outpatient/day hospital-based integrated treatment is a viable option for medically ill substance-abusing adults who would otherwise be hospitalized and is associated with higher than expected completion rates and low rate of complications. Co-locating the unit at a hospital and integrating extensive social supports appear to be key components to this model.

Acute Disease↗
PubMed2005

Teaching professionalism within a community context: perspectives from a national demonstration project.

Most medical schools now include some component of professionalism in their curriculum, ranging from "white coat" ceremonies to didactic and small-group, case-based discussions. Often this format does not provide a context for the course content nor does it necessarily make the curricular themes relevant to population groups and communities most vulnerable to the inequities and injustices present in health care. The authors describe a community-based professionalism curriculum for preclinical and clinical year medical students and report evaluation data from three years (2001-2003) of this national demonstration project. The curriculum emphasized four themes: service, community, advocacy, and ethical behavior and was based on a service-learning pedagogy applied within community-based organizations. As part of the program evaluation, 95 students from 33 medical schools between the years 2001 and 2003 (response rate: 84.8%) completed an anonymous questionnaire. When asked what did they learn about professionalism that they did not learn (or expect to learn) in their medical school curriculum, the most common themes were (1) factors and influences affecting professional behavior, with many specifically citing pharmaceutical companies and insurance carriers (46.3%); (2) the role and importance of physician advocacy on behalf of their patients (37.9%); and (3) issues specific to the needs of vulnerable and disadvantaged populations (20.0%). This project demonstrates that community-based experiences can provide unique and relevant learning in a professionalism curriculum that can complement existing medical-school-based efforts.

Adult↗
PubMed2005

Self-reported comorbidities, perceived needs, and sources for usual care for older and younger homeless adults.

BACKGROUND: While older individuals who are homeless tend to be in poorer health, it is less clear how they view their health care needs and whether their self-reported patterns for accessing health services differ from younger homeless counterparts. METHODS: Cross-sectional, community-based survey of homeless adults in Pittsburgh and Philadelphia using face-to-face interviews from population proportionate sampling of sites and random sampling of subjects. Survey questions included physical and mental health comorbidities, self-reported health care, social services and personal needs, means of economic support, and sources for usual health care. For analysis purposes, respondents were grouped by age 18 to 49 years old and 50 years old or older. RESULTS: Overall, 531 adults were interviewed, with 74 respondents 50 years old or older (13.9%). Older homeless persons were 3.6 times more likely to report a chronic medical condition, 2.8 times more likely to have health insurance, and 2.4 times more likely to be dependent on heroin than homeless persons less than 50 years old. However, they also tended to use shelter-based clinics and street outreach teams more commonly as their source of usual care (20.9% vs 10.6%, P=.02) and were significantly less likely to report a need for substance abuse treatment despite high rates of abuse. CONCLUSION: Older homeless adults have a greater disease burden than their younger counterparts. However, it is unclear whether these needs are being appropriately identified and met. There is a need for specific and targeted outreach to connect them to appropriate services.

Adolescent↗
PubMed2004

The urban safety net: can it keep people healthy and out of the hospital?

There is much discussion and debate over the relative vulnerability and capacity of the health care safety net to care for the growing numbers of uninsured and disenfranchised persons in urban poor communities. In this study, we present findings from a community-based survey of 248 adults identified at eight safety net provider sites in Baltimore, Maryland, to contextualize recent findings that described Baltimore's safety net capacity as having more hospital- and intensive service-based interventions, with higher proportions of the population reportedly unable to get care when needed compared with other cities. The average age of respondents was 41.2 years, most (87.3%) were African American, unemployed (75.8%), homeless (57.0%), and with at least one chronic medical problem (77.8%). Almost one half (47.6%) also reported a chronic mental health condition, and 51.2% reported having difficulty accessing health care services in the past. Overall, 76.9% reported accessing additional community sites for daily sustenance needs, with most of these sites community non-profit or faith-based organizations. In the multiple logistic regression model, only individuals with chronic mental health conditions were significantly more likely to report difficulties accessing health care. The lack of a Community Access Program or other structured efforts to facilitate integration of services among providers in Baltimore and an "all-payer" system that reimburses uncompensated care only for hospital admissions are postulated as two structural elements that may contribute to these findings.

Adult↗
PubMed2004

Medical debt and aggressive debt restitution practices: predatory billing among the urban poor.

BACKGROUND: Health care providers are increasingly relying on collection agencies to recoup charges associated with medical care. Little is known about the prevalence of this practice in low-income communities and what effect it has on health-seeking behavior. METHODS: Cross-sectional survey at 10 "safety net" provider sites in Baltimore, Md. Specific queries were made to underlying comorbidities, whether they had a current medical debt, actions taken against that debt, and any effect this has had on health-seeking behavior. RESULTS: Overall, 274 adults were interviewed. The average age was 43.9 years, 77.3% were African American, 54.6% were male, 47.2% were homeless, and 34.4% had less than a 12th grade education. Of these, 46.2% reported they currently had a medical debt (average, 3,409 dollars) and 39.4% reported ever having been referred to a collection agency for a medical debt. Overall, 67.4% of individuals reported that either having a current medical debt or having been referred to a collection agency for a medical debt affected their seeking subsequent care: 24.5% no longer went to that site for care; 18.6% delayed seeking care when needed; and 10.4% reported only going to emergency departments now. In the multiple logistic regression model, having less than a 12th grade education (odds ration [OR], 2.5; 95% confidence interval [CI], 1.0 to 6.0) and being homeless (OR, 4.1; 95% CI, 1.4 to 12.3) were associated with a change in health-seeking behavior while having a chronic medical condition (OR, 0.2; 95% CI, 0.1 to 0.5) and going to a community clinic for usual care (OR, 0.2; 95% CI, 0.1 to 1.0) were protective. CONCLUSIONS: Aggressive debt retrieval for medical care appears to be indiscriminately applied with a negative effect on subsequent health-seeking behavior among those least capable of navigating the health system.

Adolescent↗
PubMed2004

ASAM Patient Placement Criteria treatment levels: do they correspond to care actually received by homeless substance abusing adults?

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Adolescent↗
PubMed2004

Full disclosure of financial costs and options to patients: the roles of race, age, health insurance, and usual source for care.

The objective was to identify factors associated with financial discussions and financial disclosure of medical costs within a low-income urban community. The method used was a cross-sectional community-based survey in Allegheny County, Pennsylvania. The survey was conducted door-to-door and at area food pantries. Two hundred and twenty six adults were interviewed. Overall, 76.1% reported having a usual source for care and 73.0% had health insurance. Thirty nine and four tenths percent reported having been asked about their ability to pay for health services; this was more common among African Americans (OR 5.2; 95% CI 1.73-15.84), those with no health insurance (OR 4.3; 95% CI 1.01-17.89), and those less than 45 years old (OR:2.9; 95% CI 1.03-8.28). Only 10.6% reported being told how much a health visit would cost. Overall, 30.1% reported their provider made payment allowances for medical bills, with white respondents 2.5 times more likely and those persons identifying an ambulatory site for care 2.6 times more likely to report this. Overall, 30.5% reported being referred to a collection agency for unpaid medical bills; this was 2.4 times more common among those individuals identifying a non-ambulatory usual site for care. Significant race and socio-economic disparities exist in discussions about and access to financial resources to pay for medical care. Expanding the availability of financial assistance is critical to improving access to health care.

Adult↗
PubMed2004

Self-reported changes in drug and alcohol use after becoming homeless.

OBJECTIVES: We identified substance use patterns and factors associated with increased substance use after users become homeless. METHODS: We carried out a 2-city, community-based survey that used population-proportionate sampling of 91 sites with random selection at each site. RESULTS: Five hundred thirty-one adults were interviewed; 78.3% of them met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for substance abuse or dependence. Most of those who met the criteria reported using drugs and alcohol less since they became homeless, commonly because they were in recovery. Factors independently associated with increased use were no health insurance (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.02, 2.58), alcohol abuse or dependence (OR = 3.5; 95% CI = 1.85, 6.78), and selling plasma (OR = 2.6; 95% CI = 1.32, 5.14) or panhandling (OR = 3.0; 95% CI = 1.65, 5.55) to acquire drugs. CONCLUSIONS: Becoming homeless plays a role in self-reported substance use. Multiservice treatment programs and tailored interventions for homeless persons are needed.

Adult↗
PubMed2003

Health care of homeless veterans.

It is important to understand the needs of those veterans who are homeless. We describe characteristics of homeless male veterans and factors associated with needing VA benefits from a two-city, community survey of 531 homeless adults. Overall, 425 were male, of whom 127 were veterans (29.9%). Significantly more veterans had a chronic medical condition and two or more mental health conditions. Only 35.1% identified a community clinic for care compared with 66.8% of non-veterans (P <.01); 47.7% identified a shelter-based clinic and 59.1% reported needing VA benefits. Those reporting this need were less likely to report a medical comorbidity (58.7% vs 76.9%; P =.04), although 66.7% had a mental health comorbidity and 82.7% met Diagnosic Screening Manual (DSM)-IIIR criteria for substance abuse/dependence. They were also significantly more likely to access shelter clinics compared with veterans without this need. Homeless veterans continue to have substantial health issues. Active outreach is needed for those lacking access to VA services.

Adult↗
PubMed2002

Urban homelessness and poverty during economic prosperity and welfare reform: changes in self-reported comorbidities, insurance, and sources for usual care, 1995-1997.

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P <.001) and mental health comorbidity (44.9% vs. 36.9%, P =.04) and required more chronic medication (52.1% vs. 30.3%, P <.001). More respondents in 1997 than 1995 reported having no health insurance (41.4% vs. 29.4%, P <.001). While there was no difference in the overall proportion reporting a source for usual care (78.3% in 1997 vs. 80.2% in 1995, P =.55), fewer persons reported use of the emergency department and more persons reported using a shelterbased clinic for usual care in 1997 compared with 1995. These findings suggest more need for medical care among homeless and urban poor persons in 1997 compared with 1995 and support the continued need for outreach and support services despite a vigorous economy.

Adolescent↗
PubMed2002

Students' attitudes toward indigent patients.

Second- and fourth-year medical students were surveyed about the influence of medical education on their attitudes towards indigent patients and its role in career planning.

Attitude of Health Personnel↗
PubMed2002

Outpatient treatment entry and health care utilization after a combined medical/substance abuse intervention for hospitalized medical patients.

CONTEXT: Drug-abusing patients utilize extensive amounts of health services resources, yet the acute medical hospitalization has typically not been used effectively to engage patients in substance abuse treatment. OBJECTIVES: To assess the effect of an integrated substance abuse/acute medical care day hospital (DH) intervention. DESIGN AND SETTING: Prospective, consecutive chart review of patients referred to a day hospital program from the medicine service at an urban tertiary care teaching hospital. From the referral cohort, a comparison group receiving usual care was identified. PARTICIPANTS: One hundred twenty adult medicine inpatients with active substance abuse and self-identified motivation to enter treatment. MAIN OUTCOME MEASURES: Outpatient substance abuse treatment entry and post-intervention health services utilization. RESULTS: Following DH treatment, 50.6% entered further outpatient substance abuse treatment (vs 2.4% comparison patients; P <.001). There was a significant increase in ambulatory medical visits for DH patients (pre-6 month 0.49 vs post-6 month 3.46; P <.001), greater than the change noted for comparison patients. However, there was no difference noted in pre-post hospitalization or emergency department utilization following the DH intervention. CONCLUSIONS: A DH program for substance abusing hospitalized medicine patients that introduces substance abuse treatment during treatment for an acute medical illness does appear to improve outpatient substance abuse treatment entry and ambulatory care utilization after hospital discharge.

Acute Disease↗