Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System.

OBJECTIVES: Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005-2007), during (2008-2009) and after (2010-2011) the economic contraction in the USA. METHODS: Data from the restricted National Violent Death Reporting System (2005-2011) for male and female suicide decedents aged 20 years and older were analysed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol content ≥0.08 g/dL) prior, during and after the downturn. RESULTS: The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005-2007 to 23.9% in 2008-2011. Compared with the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first 2 years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI 1.02 to 1.27) increased risk of intoxication in 2010-2011 compared with 2005-2007. CONCLUSIONS: These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.

Consumer, provider, and informal caregiver opinions on psychiatric advance directives.

Psychiatric advance directives (PADs) are legal documents that permit competent adults to make choices in the present about their future psychiatric treatment if they lose their decision-making capacity. PADs may provide for the appointment of surrogate decision-makers. The present project was undertaken to obtain opinions from the consumer (the patient), provider, and informal caregiver/surrogate about the Oregon PAD. Results of this pilot study show that the majority of no-PAD group consumers reported that they did not get enough help with PAD preparation. The PAD group consumers reported feeling empowered by PAD preparation, but at the follow-up interview, they were less enthusiastic and more critical of PAD policy that was relevant to implementation. Many providers also were concerned about successful PAD implementation. PAD legislation alone does not translate into adequate policy.

Access to substance abuse treatment services under the Oregon Health Plan.

CONTEXT: The shift to Medicaid managed care has raised numerous concerns about access to publicly funded substance abuse treatment. The implementation of a capitated chemical dependency benefit within the Oregon Health Plan in 1995 provided an opportunity to study the impact of funding mechanisms on access. OBJECTIVES: To determine to what extent access to publicly funded substance abuse treatment changed following the shift to managed care in Oregon and to examine factors associated with that change. DESIGN: Analysis of statewide treatment and Medicaid eligibility data. SETTING AND PATIENTS: All Medicaid-eligible persons aged 12 to 64 years who were enrolled in the Oregon Health Plan during 1994 (88,320), 1996 (170,387), 1997 (160,929), or 1998 (149,877). MAIN OUTCOME MEASURES: Access rates (the number of unique individuals admitted to treatment during a calendar year divided by the average number of enrolled members) computed before (1994) and after (1997) implementation of the capitated benefit. Analyses were replicated with data for 1996 and 1998. RESULTS: The percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following the shift to managed care. For 1996 and 1998, the rates were 6.9% and 7.7%, respectively. Access rates varied considerably among the 7 largest prepaid health plans after adjusting for case mix. Operating characteristics of these prepaid health plans, such as the method of reimbursing treatment providers, were significant predictors of access after controlling for member characteristics. CONCLUSION: According to our analyses, Medicaid-eligible persons in Oregon observed an increase in access to substance abuse treatment after a shift to managed care. JAMA. 2000;284:2093-2099.

Lessons learned.

Mental health care reform in the public sector remains a local proposition. Oregon has thus far been able to avoid major failures and has modest successes to report. Although the road to achieving all that was envisioned at the outset remains long, the inclusive process followed gives reason for hope.

Background on the Oregon Health Plan.

Because of limited resources, the health care industry has been forced to choose how funds are spent. Public fee-for-service systems have begun to face the hard choices inherent in managed care. The Oregon Health Plan was designed to provide a rational approach to addressing these changes directly.

Overview of Medicaid managed behavioral health care.

The Oregon Health Plan is being implemented at a time when many states are revising their Medicaid mental health programs. A national overview places this state's efforts into context.

The mental health organizations.

The mental health organizations in the mental health phase-in were Oregon's pioneers moving into public managed care. A delicate balance between county mental health authority and private expertise was struck locally to yield a variety of organizational models across the state.

The validity of medicaid pharmacy claims for estimating drug use among elderly nursing home residents: The Oregon experience.

This study compared computerized Medicaid pharmacy claims data for nursing home residents with chart data to establish how well the claims data identified those receiving drugs within three different psychoactive drug classes (yes/no for each class) and how well the claims estimated total within-class average daily dose. Percent agreement, positive predictive value (PPV), and negative predictive value (NPV) for drug exposure were over 85% for each class. Kappas were excellent for antipsychotics and antidepressants, and good for anxiolytics. Correspondence was lower for average daily dose. Using an algorithm that credits some but not all doses associated with overlapping claims, correlations ranged from 0.97 to 0.66. Agreement on therapeutic dose was excellent for antipsychotics (kappa = 0.81) and fair to good for antidepressants and anxiolytics (kappa = 0.63, and kappa = 0.52, respectively). The findings suggest that Medicaid pharmacy claims data are reasonably accurate for quality assurance and accreditation purposes.

Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression.

BACKGROUND: The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms. METHODS: Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis. RESULTS: Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status. CONCLUSIONS: New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

Mental health in the Oregon Health Plan: fragmentation or integration?

The Oregon Health Plan was implemented in 1994 with a 50% expansion of Medicaid enrollment to include some of the working poor. Over 75% of Oregon Medicaid clients are now enrolled in health maintenance organizations (HMOs). Outpatient chemical dependency services have been capitated since May 1995. Capitated mental health services have been provided for the 25% of eligibles who live in demonstration counties since January 1995. Expansion and capitation appear to have been achieved without major trauma. More challenging has been the attempted integration of public sector behavioral health services with private sector health plans. Stakeholders interviewed for this study were especially concerned about the long-term impact on Medicaid clients with chronic mental illness. Strong leadership and clear policies regarding the mixture of public, private nonprofit, and private for profit entities are necessary if the state is to achieve its aim of integration without fragmenting a system of care for people with severe mental illness.

Community mental health program efficiency.

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.

Changing patterns of antidepressant use and costs in a health maintenance organisation.

This study examined changes in the utilisation and costs of different antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), and changes in the use of mental health services in a US health maintenance organisation (HMO) over the 8-year period following the introduction of SSRIs. It was hypothesised that SSRIs would be used increasingly in this setting, and that SSRI users would show a pattern of mental health service utilisation that was indicative of more severe psychiatric illnesses or prior treatment failures. Both hypotheses were accepted. The use of antidepressants nearly tripled over the 8-year period, with SSRIs showing the largest increase; per capita antidepressant costs increased more than 10-fold, largely because of the high cost per unit of SSRIs. Estimated daily doses of SSRIs were largely within the recommended ranges, although the duration of use was short if their primary purpose was the treatment of depression. Incident (first-time) users of SSRIs, and patients who switched to SSRIs from other antidepressants, used more inpatient and outpatient mental health services than users of other antidepressants. Use of the psychiatric hospital among antidepressant users increased, then decreased back to its first year level, psychiatric hospital days appeared to decrease over time, and outpatient mental health visits increased. The inverse relationship between use of SSRIs and use of inpatient mental health services suggests the need for a cost-effectiveness analysis in this setting.

Enrollment duration, service use, and costs of care for severely mentally ill members of a health maintenance organization.

BACKGROUND: The rapid growth of prepaid health care and the increasing enrollment of Medicaid clients in health maintenance organizations (HMOs) raise concerns about the adequacy of services for persons with severe mental illness in capitated health plans. Uncontrolled studies have suggested that enrollment of HMO members with mental illness may be prematurely terminated. METHODS: We identified 250 adult Kaiser Permanente Northwest Region (Portland, Ore) members who were enrolled during 1986 or 1987 and had chart diagnoses of schizophrenia or bipolar disorder. Severely mentally ill subjects were matched by age and sex with control HMO members with and without diabetes mellitus. Records of the HMO and the state mental health agency were reviewed to determine HMO enrollment duration, private and public service utilization, and HMO costs of care during the 4-year follow-up period. RESULTS: The severely mentally ill subjects had 42 months of HMO enrollment during the follow-up period compared with 37 months for the controls without diabetes mellitus and 47 months for the patients with diabetes mellitus (P < .001). When HMO enrollment prior to the study was taken into account, the severely mentally ill subjects and those with diabetes mellitus had similar membership duration. Among the severely mentally ill subjects, community mental health service use was related to longer duration of HMO enrollment (P < .05) but HMO costs of care per member per month were not related to retention. The severely mentally ill subjects were high users of mental health services but their use of general medical care was similar to that of the controls without diabetes mellitus. CONCLUSIONS: This controlled study found no evidence for early termination of HMO members with costly mental illness. Use of community mental health care was associated with longer duration of HMO enrollment.

Lithium use and discontinuation in a health maintenance organization.

OBJECTIVE: For decades, lithium has been prescribed to treat bipolar disorder. Its efficacy has been documented by clinical trials and by data from specialized clinics. An issue of considerable interest is the use of lithium in managed care systems. This project examined the use of lithium and its continuity of use by enrollees of a health maintenance organization (HMO). METHOD: In a 6-year longitudinal cohort study, 1,594 lithium users aged 15 years and older who were enrolled in an HMO were followed from 1986-1991. Data were obtained from automated databases and from medical record review of a random 5% subsample of the group (N = 74). RESULTS: Bipolar disorder was the most frequent morbidity treated. Eighty-four percent (N = 62 or 74) received services from a psychiatrist. Annual prevalence of lithium use increased over the 6-year period from 1.4 to 2.3 persons per thousand HMO members. Duration of use varied widely with some long-term but many short-term users. Discontinuation of treatment was associated with evaluated rates of psychiatric hospitalization and use of psychiatric emergency services. Lithium users were much more likely to receive a variety of other psychotropic drugs than nonusers of the same sex and age. CONCLUSIONS: Lithium use in this population was more often sporadic than continuous. Discontinuation of lithium was associated with psychiatric hospitalization. If lithium is to be a cost-effective treatment for bipolar disorder, managed care systems will need to improve adherence to drug treatment regimens.

Comparing period prevalences with application to drug utilization.

Period prevalence is frequently measured in studies based on administrative data such as that from health maintenance organizations. For example, treated prevalence and drug utilization prevalence are important measures that are typically defined in relationship to a specified time period. Often one wishes to compare administrative data with period prevalences based on national surveys. It may also be of interest to compare period prevalences from two (or more) different data sources. This comparison is not straightforward owing to the problem of "person-time at risk." This article reviews the values and drawbacks of period prevalence as compared with cumulative incidence. L ife table methodology is described for comparing period prevalence data from administrative databases with survey results. This technique can be extended to the comparison of period prevalence observations from two or more administrative data bases. Examples are given pertaining to hypnotic drug use and the treatment of schizophrenia.

A capitated payment system for involuntary mental health clients.

This DataWatch examines an outpatient capitated payment system, in the state of Oregon, designed to enhance community services for persons with chronic mental illness who had repeatedly been hospitalized involuntarily. Special state funds and Medicaid dollars were used to pay providers prospectively on a risk-adjusted basis for the delivery of outpatient mental health services. During the three-year study period clients were able to be discharged from the state hospital. Although the data are not straightforward, capitated clients' use of the state mental hospital seems to have declined somewhat more than that of comparison subjects. Outpatient service use was modest and appeared to have little relationship to a client's level of illness severity. Indeed, it was not possible to predict prospectively these clients' outpatient mental health services expenditures.