Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case.

There is a growing body of evidence on the impact of the environment on health and well-being. This study focuses on the impact of visual artworks on the well-being of psychiatric patients in a multi-purpose lounge of an acute care psychiatric unit. Well-being was measured by the rate of pro re nata (PRN) medication issued by nurses in response to visible signs of patient anxiety and agitation. Nurses were interviewed to get qualitative feedback on the patient response. Findings revealed that the ratio of PRN/patient census was significantly lower on the days when a realistic nature photograph was displayed, compared to the control condition (no art) and abstract art. Nurses reported that some patients displayed agitated behaviour in response to the abstract image. This study makes a case for the impact of visual art on mental well-being. The research findings were also translated into the time and money invested on PRN incidents, and annual cost savings of almost $US30,000 a year was projected. This research makes a case that simple environmental interventions like visual art can save the hospital costs of medication, and staff and pharmacy time, by providing a visual distraction that can alleviate anxiety and agitation in patients.

Clinical and laboratory assessment of distal peripheral nerves in Gulf War veterans and spouses.

BACKGROUND: The prevalence of symptoms suggesting distal symmetric polyneuropathy (DSP) was reported to be higher among deployed veterans (DV) to the Persian Gulf in 1990-1991 than to control non-deployed veterans (NDV). The authors therefore compared the prevalence of DSP by direct examination of DV and their spouses to control NDV and spouses. METHODS: The authors performed standardized neurologic examinations on 1,061 DV and 1,128 NDV selected from a cohort of veterans who previously participated in a national mail and telephone survey. Presence of DSP was evaluated by history, physical examination, and standardized electrophysiologic assessment of motor and sensory nerves. Similar examinations were performed without electrophysiologic tests in 484 DV spouses and 533 NDV spouses. Statistical analyses were performed with appropriate adjustments for the stratified sampling scheme. RESULTS: No differences between adjusted population prevalence of DSP in DV and NDV were found by electrophysiology (3.7% vs 6.3%, p = 0.07), by neurologic examination (3.1% vs 2.6%, p = 0.60), or by the methods combined (6.3% vs 7.3%, p = 0.47). Excluding veterans with non-military service related diseases that may cause DSP did not alter outcomes. DV potentially exposed to neurotoxins from the Khamisiyah ammunition depot explosion did not significantly differ in DSP prevalence compared to non-exposed DV. The prevalence of DSP in DV spouses did not differ from NDV spouses (2.7% vs 3.2%, p = 0.64). CONCLUSIONS: Neither veterans deployed during the Gulf War era nor their spouses had a higher prevalence of DSP compared to NDV and spouses.

Toward a national consumer survey: evaluation of the CABHS and MHSIP instruments.

This article describes a study evaluating the Consumer Assessment of Behavioral Health Survey (CABHS) and the Mental Health Statistics Improvement Program (MHSIP) surveys. The purpose of the study was to provide data that could be used to develop recommendations for an improved instrument. Subjects were 3,443 adults in six behavioral health plans. The surveys did not differ significantly in response rate or consumer burden. Both surveys reliably assessed access to treatment and aspects of appropriateness and quality. The CABHS survey reliably assessed features of the insurance plan; the MHSIP survey reliably assessed treatment outcome. Analyses of comparable items suggested which survey items had greater validity. Results are discussed in terms of consistency with earlier research using these and other consumer surveys. Implications and recommendations for survey development, quality improvement, and national policy initiatives to evaluate health plan performance are presented.

Use of consumer ratings for quality improvement in behavioral health insurance plans.

BACKGROUND: The Consumer Assessment of Behavioral Healthcare Services (CABHS) survey collects consumers' reports about their health care plans and treatment. The use of the CABHS to identify opportunities for improvement, with specific attention to how organizations have used the survey information for quality improvement, is described. METHODS: In 1998 and 1999, data were collected from five groups of adult patients in commercial health plans and five groups of adult patients in public assistance health plans with services received through four organizations (one of three managed behavioral health care organizations or a health system). Patients who received behavioral health care services during the previous year were mailed the CABHS survey. Non-respondents were contacted by telephone to complete the survey. RESULTS: Response rates ranged from 49% to 65% for commercial patient groups and from 36% to 51% for public assistance patients. Promptly getting treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services, received the least positive responses, whereas questions about communication received the most positive responses. In addition, questions about access- and plan-related aspects of quality showed the most interplan variability. Three of the organizations in this study focused quality improvement efforts on access to treatment. DISCUSSION: Surveys such as the CABHS can identify aspects of the plan and treatment that are improvement priorities. Use of these data is likely to extend beyond the behavioral health plan to consumers, purchasers, regulators, and policymakers, particularly because the National Committee for Quality Assurance is encouraging behavioral health plans to use a similar survey for accreditation purposes.

Heritability of self-reported health.

OBJECTIVE: To explore the contribution of genes and environmental factors to variation in a common measure (i.e., a five-point--excellent, very good, good, fair, and poor--Likert scale) of self-reported health. DATA SOURCES: Data were analyzed from 4,638 male-male twin pair members of the Vietnam Era Twin (VET) Registry who responded to a 1987 health survey. STUDY DESIGN: Varying models for the relationship between genetic and environmental influences on self-reported health were tested in an attempt to explain the relative contributions of additive genetic, shared and nonshared environmental effects, and health conditions reported since 1975 to perceived health status. DATA COLLECTION: A mail and telephone survey of health was administered in 1987 to VET Registry twins. PRINCIPAL FINDINGS: Variance component estimates under the best-fitting model included a 39.6 percent genetic contribution to self-reported health. In a model which included the effect of health condition, genes accounted for 32.5 percent and health condition accounted for 15.0 percent of the variance in self-reported health. The magnitude of the genetic contribution to perceived health status was not significantly different in a model with or without health condition. CONCLUSIONS: These data suggest over one-third of the variability of self-reported health can be attributed to genes. Since perceived health status is a major predictor of morbidity, mortality, and health services utilization, future analyses should consider the role of heritable influences on traditional health services variables.

Clinical status. Charting for outcomes in behavioral health.

This article summarizes the criteria that clinical outcome data must meet to be useful in the quest for empirical effectiveness data about mental health services. Although demand is high for such data, its potential usefulness is just beginning to be tapped. The mental health field presents unique challenges for implementing outcome tracking systems, for analyzing and reporting results, and for using results to improve the processes of care. Measuring outcomes will not automatically improve care or ensure quality. It may, however, provide information that will be useful in guiding efforts to improve the quality of mental health services.

Development of a consumer survey for behavioral health services.

A consumer survey was designed to assess the quality of mental health and substance abuse services and evaluate insurance plans that provide such services. This paper describes the development of the Consumer Assessment of Behavioral Health Services instrument, which began with a review of existing consumer satisfaction surveys and input from several groups working toward development of nationally standardized satisfaction instruments. Consumer focus groups were used to ensure that all the important domains of quality were included, and group members were interviewed to ensure that all items on the instrument were understandable. Results of a pilot test conducted with 160 consumers, 82 enrolled in Medicaid plans and 78 in commercial plans, suggested that the survey was able to distinguish between the two groups in terms of evaluations of their care and insurance plans. Future efforts will focus on further testing of larger, more diverse samples and on developing scoring and reporting formats for the survey that will be useful to consumers and purchasers in choosing behavioral health services and plans.

Assessing the quality of psychiatric care: research methods and application in clinical practice.

The drive to contain the costs of health care in the United States is focusing attention on how quality of care is affected. This article discusses research methods for assessing the quality of psychiatric care and reviews findings from some major studies evaluating care. These findings are mixed, highlighting areas in which quality of care is less than optimal, as well as the importance of continued research and the need to develop better research methods. Evidence-based criteria and more-sensitive risk-adjustment techniques must be employed if data on quality are to yield fair comparisons among health plans. The challenge is to refine the methods now in use at both the research and clinical levels, so that better-quality assessments can be made for policy formulation, physician education, and consumer choice.

Genetic and environmental contributions to healthcare need and utilization: a twin analysis.

OBJECTIVE: An exploratory study to examine the genetic and environmental influences on healthcare-seeking behavior for four health conditions (high blood pressure, mental health problems, joint disorders, and hearing problems). DATA SOURCES: Data collected from 3,602 male-male twin pair members of the Vietnam Era Twin (VET) Registry. STUDY DESIGN: Varying models for the relationship between genetic and environmental influences on health condition liability and on treatment use were tested in an attempt to explain the relative contributions of additive genetic, common, and unique environmental effects to health condition and treatment use. DATA COLLECTION: A mail and telephone survey of general health status was administered in 1987 to VET Registry twins. PRINCIPAL FINDINGS: Variance component estimates under the best-fitting model for the genetic component ranged from 24 percent to 52 percent for the condition status and from 42 percent to 56 percent for treatment-seeking behavior. CONCLUSIONS: Utilization models that consider only environmental parameters will leave a large percentage of variability unexplained. Familial patterns have an impact not only on disease susceptibility but also on healthcare utilization, thereby having lifelong implications for social and fiscal constraints placed on the healthcare system. Thus, explanatory models for healthcare utilization behavior should consider the contribution of genetic factors in the decision to seek and use health services.

Assessing outcomes in clinical practice.

We are witnessing a remarkable explosion in interest and activity in quantifying outcomes and using these measures to enhance the value of clinical care. Outcomes assessment has become an imperative for clinical practice. This paper first will offer criteria for an ideal system of outcomes assessment. The paper will then review the principal domains of assessment for psychiatric practice and provide examples of instruments available in each domain. We will then describe the use of two instruments, one for clinical outcome and one for interpersonal aspects of patient satisfaction, developed and used at McLean Hospital. The relation between outcomes assessment and outcomes management will then be discussed. Finally, we will discuss the fundamental questions a clinical group or facility might consider in choosing outcomes measurement instruments.

The impact of preadmission approval and continued stay review on hospital stay and outcome among children and adolescents.

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990. Demographic and clinical characteristics, hospital ownership type, and preadmission approval or continued stay review were used as independent variables in a multiple regression model to predict length of stay and clinical outcome. Results indicate that the model accounted for 27% of the variance in length of stay. Previous psychiatric hospitalization and for-profit hospital status predicted longer hospitalization. Clinical outcome was not significantly predicted by the model. Managed care did not predict either length of stay or clinical outcome. Implications for health care reform are discussed.

Assessment of subjective distress by patients' self-report versus structured interview.

Comparison was made of symptom and behavior scores obtained by structured interview versus self-report using the Behavior and Symptom Identification Scale. Psychiatric hospital admissions were randomly assigned to 1 of 3 assessment groups, structured interview, self-report, or choice of procedure. Analysis indicated that patients in the self-report group reported significantly greater difficulty on 1 of 5 dimensions assessed by the scale. The results suggest that a self-report questionnaire form of the measure is a viable alternative to the structured interview.

A twin study of the association of post-traumatic stress disorder and combat exposure with long-term socioeconomic status in Vietnam veterans.

This study examines the association between post-traumatic stress disorder (PTSD) and combat exposure with the socioeconomic status of 2210 male monozygotic veteran twin pairs in 1987. In the unadjusted analysis on individuals, modest correlations indicated that those with PTSD were more likely to have been divorced, and less likely to be currently employed or to achieve high status in income, education or occupation. In the crude analysis of veterans not suffering from PTSD, there were small positive correlations between combat level experienced and the likelihood of ever being married, ever being divorced, and the number of years employed at the current job. However, when we examined identical twins discordant for PTSD, and adjusted for pre-military and military service factors, only unemployment remained significant. Likewise, in combat-discordant twins, no significant effects on the socioeconomic indicators were seen. We conclude that PTSD and combat experience in Southeast Asia have not had a major impact on the socioeconomic status of veterans.

A strategy for assembling samples of adult twin pairs in the United States.

In this paper we develop a methodology for the identification of large numbers of U.S. adult twin pairs. Data for this study derive from the U.S. Department of Defense and the Vietnam Era Twin (VET) Registry. The Department of Defense identified potential male twins (n = 10,002) using a computerized record linkage algorithm based on the same last name, same date of birth, and the same first five digits of the Social Security number. Twinship was confirmed by comparison with the Vietnam Era Twin Registry. We developed a logistic regression model that predicts the probability that a paired record identifies twins based on the absolute difference in the last four digits in the Social Security number, the age of issuance of the Social Security number, and the frequency of occurrence of the last name. We used the estimated coefficients derived from this regression model to assign predicted probabilities of being a twin to each matched record. There is a close correspondence between the observed and expected number of twins when evaluated across deciles of predicted probabilities of being a twin; the value of the Harrell's c index (c = 0.68 +/- 0.0004) indicates the overall predictive accuracy of the regression equation. The results from this study demonstrate the feasibility of identifying adult male-male twin pairs from any large computerized database that contains name, date of birth and Social Security number. However, the selection criteria used in the creation of the computer database must be clearly specified to avoid constructing a biased sample of twins.

Case-based reimbursement for psychiatric hospital care.

A fixed-prepayment system (case-based reimbursement) for patients initially requiring hospital-level care was evaluated for one year through an arrangement between a private nonprofit psychiatric hospital and a self-insured company desiring to provide psychiatric services to its employees. This clinical and financial experiment offered a means of containing costs while monitoring quality of care. A two-group, case-control study was undertaken of treatment outcomes at discharge, patient satisfaction with hospital care, and service use and costs during the program's first year. Compared with costs for patients in the control group, costs for those in the program were lower per patient and per admission; cumulative costs for patients requiring rehospitalization were also lower. However, costs for outpatient services for patients in the program were not calculated. Treatment outcomes and patients' satisfaction with hospital care were comparable for the two groups.

Validity of record ratings of the Global Assessment Scale.

The Global Assessment Scale (GAS) is a comprehensive rating of psychiatric status that is usually based on face-to-face interviews. Validity has not been established for the use of the GAS when it is based on secondary sources of information about the patient, source of patient information, although secondary sources have been used for this purpose. The current study examined agreement between GAS ratings based on medical records and ratings based on face-to-face interviews. Results showed moderate agreement between the two sets of ratings, with the intraclass correlation-coefficient (ICC) equaling .62. Record-based (R)-GAS ratings were upwardly biased and were restricted in range when compared with interview-based (I)-GAS ratings. A case-by-case analysis showed that the disagreement could be accounted for by inconsistent documentation of the degree of functional impairment in the most severely disturbed patients. We conclude the following: If R-GAS ratings are used, designs should be modified to adjust for probable overestimated functioning of the most severely disturbed patients.

The Vietnam Era Twin (VET) Registry: method of construction.

A Vietnam Era (1964-1975) Twin Registry of American male-male veterans born between 1939 and 1955 has been developed to provide a study sample for research evaluating the impact of Vietnam service on the medical and psychosocial aspects of health. In preparation for developing the Registry, several alternative sources of twins and methods for identifying twins were investigated. A computerized database of veterans discharged from the military after 1967 was selected as the source because it contains about 50% of the total Vietnam era veteran population, is reasonably unbiased, and provides a feasible method for identifying twins. Twins were identified using an algorithm which involved matching entries on the database for same last name, different first name, same date of birth, and similar social security number. Twin status was confirmed by review of military records. The registry, now complete, is composed of 7,400 twin pairs. It will be an important resource for future research projects.