Rehospitalization risk factors for psychiatric treatment among elderly Medicaid beneficiaries following hospitalization for a physical health condition.

OBJECTIVES: Hospitalizations for physical health problems can cause great mental health challenges. We examined risk factors and expenditures for early readmission for inpatient psychiatric treatment following a hospitalization for a non-psychiatric condition. METHOD: We used eight years of Florida Medicaid enrollment and claims data for (FY 2003-2011) as well as data obtained from the Florida Center for Health Information and Policy Analysis, Inpatient Hospital Database, to identify episodes of hospitalization for all Medicaid-enrolled older adults. There were a total of 781,660 index hospitalizations for non-behavioral health-related hospitalizations, 2690 (0.3%) of which resulted in a behavioral health-related rehospitalization within 30 days after discharge. We estimated the relative risk of early rehospitalization using Cox proportional hazards regression. RESULTS: Participants (n = 276,254) were 76.8 ± 8.3 years old; 68.4% female and 43.5% White. As expected, we found that having a preexisting behavioral health disorder (including severe mental illness, substance use disorder, or dementia) greatly increased the risk of readmission. We also found that male gender increased the risk of early readmission. Older age, being Black and having one or more comorbid medical conditions as identified by the Charlson Index were associated with substantially reduced risk. CONCLUSION: Identifying hospitalized patients with psychiatric conditions, as well as those who are relatively young within this age group, male, White rather than Black or of other race, alcohol abusers, and those without comorbid conditions, and providing them with care to address their behavioral needs may help in efforts to reduce early rehospitalizations for psychiatric conditions.

Predictors of behavioural health service use and associated expenditures: Individuals with TBI in Pinellas County.

OBJECTIVE: Traumatic brain injury (TBI) is a major public health concern. Such injuries often result in dramatic changes in the individual's life-course due to the associated complex co-morbidities. Limited research exists on the use and expenditures incurred for behavioural healthcare services post-TBI. This study examined predictors of behavioural service use, incarceration and associated expenditures for individuals with TBI. METHODS: Emergency Medical Services and Medicaid Claims data were used to identify individuals diagnosed with a TBI in Pinellas County, Florida, in FY 2005. Ten statewide and local administrative data sets from 2005-2008 were employed to determine subject's demographic characteristics, criminal justice encounters, behavioural health services use and associated expenditures. Average annual expenditures and use of mental health, substance abuse and criminal justice services over a 3-year period were determined. RESULTS: A total of 1005 individuals diagnosed with TBI were identified and, of these, 910 survived the 3-year period. Study participants were grouped into high and low behavioural health expenditure groups. Those in the high expenditure group were more likely to be male, white and to have received behavioural health services. CONCLUSIONS: This study provides new information about predictors of behavioural health service use and Medicaid expenditures for Floridians with TBI.

The 70S ribosome modulates the ATPase activity of Escherichia coli YchF.

YchF is one of two universally conserved GTPases with unknown cellular function. As a first step toward elucidating YchF's cellular role, we performed a detailed biochemical characterization of the protein from Escherichia coli. Our data from fluorescence titrations not only confirmed the surprising finding that YchFE.coli binds adenine nucleotides more efficiently than guanine nucleotides, but also provides the first evidence suggesting that YchF assumes two distinct conformational states (ATP- and ADP-bound) consistent with the functional cycle of a typical GTPase. Based on an in vivo pull-down experiment using a His-tagged variant of YchF from E. coli (YchFE.coli), we were able to isolate a megadalton complex containing the 70S ribosome. Based on this finding, we report the successful reconstitution of a YchF•70S complex in vitro, revealing an affinity (KD) of the YchFE.coli•ADPNP complex for 70S ribosomes of 3 µM. The in vitro reconstitution data also suggests that the identity of the nucleotide-bound state of YchF (ADP or ATP) modulates its affinity for 70S ribosomes. A detailed Michaelis-Menten analysis of YchF's catalytic activity in the presence and the absence of the 70S ribosome and its subunits revealed for the first time that the 70S ribosome is able to stimulate YchF's ATPase activity (~10-fold), confirming the ribosome as part of the functional cycle of YchF. Our findings taken together with previously reported data for the human homolog of YchF (hOLA1) indicate a high level of evolutionary conservation in the enzymatic properties of YchF and suggest that the ribosome is the main functional partner of YchF not only in bacteria.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics.

OBJECTIVES: The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida. DESIGN: This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database. SETTING: Medicaid-certified NHs in Florida (N= 584). PARTICIPANTS: Medicaid-enrolled NH residents (N= 32,604). RESULTS: Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination. CONCLUSION: Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Predictors of preventable nursing home hospitalizations: the role of mental disorders and dementia.

OBJECTIVES: Nursing home (NH) hospitalizations place an enormous economic burden on an already overtaxed American healthcare system. Hospitalizations for "ambulatory care-sensitive" (ACS) conditions are considered preventable, as these are physical health conditions that can potentially be treated safely in a NH. The authors examined risk factors, including mental disorders and dementia, for hospitalization of Medicaid-enrolled NH residents with ACS conditions during fiscal year 2003-2006. METHODS: The authors merged Medicaid claims and enrollment data and Online Survey Certification and Reporting information for 72,251 Medicaid-enrolled NH residents in 647 NHs in Florida. The authors identified at least one ACS hospitalization in 8,382 residents for a total of 10,091 hospital admissions (18.5% of all hospitalizations). The authors used Cox proportional hazard regression to assess time to the first ACS hospitalization. RESULTS: In a fully adjusted model, younger age, non-white race, dementia, and serious mental disorder were associated with greater risk of ACS hospitalization. In addition, residents with a diagnosed mental disorder and no dementia incurred relatively high expenditures for ACS hospitalizations. Among facility characteristics, participants from for-profit facilities, facilities that were not a member of a chain, had more Medicaid recipients, and fewer than 120 beds had greater risk of ACS hospitalizations. CONCLUSIONS: Attention to the identified predictors of hospitalization for ACS conditions, which are potentially preventable, could reduce the risk and cost of these hospitalizations among Medicaid-enrolled NH residents. The need to reduce unnecessary hospitalization will become only more urgent as the population ages and healthcare expenses continue to escalate.

The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents.

OBJECTIVE: To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents. METHODS: Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset. RESULTS: Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk. CONCLUSIONS: Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents.

Risk for suicide among medicaid beneficiaries.

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.

Isolation and analysis of the genetic diversity of repertoires of VSG expression site containing telomeres from Trypanosoma brucei gambiense, T. b. brucei and T. equiperdum.

BACKGROUND: African trypanosomes (including Trypanosoma brucei) are unicellular parasites which multiply in the mammalian bloodstream. T. brucei has about twenty telomeric bloodstream form Variant Surface Glycoprotein (VSG) expression sites (BESs), of which one is expressed at a time in a mutually exclusive fashion. BESs are polycistronic transcription units, containing a variety of families of expression site associated genes (ESAGs) in addition to the telomeric VSG. These polymorphic ESAG families are thought to play a role in parasite-host adaptation, and it has been proposed that ESAG diversity might be related to host range. Analysis of the genetic diversity of these telomeric gene families has been confounded by the underrepresentation of telomeric sequences in standard libraries. We have previously developed a method to selectively isolate sets of trypanosome BES containing telomeres using Transformation associated recombination (TAR) cloning in yeast. RESULTS: Here we describe the isolation of repertoires of BES containing telomeres from three trypanosome subspecies: Trypanosoma brucei gambiense DAL 972 (causative agent of West-African trypanosomiasis), T. b. brucei EATRO 2340 (a nonhuman infective strain) and T. equiperdum STIB 818 (which causes a sexually transmitted disease in equines). We have sequenced and analysed the genetic diversity at four BES loci (BES promoter region, ESAG6, ESAG5 and ESAG2) from these three trypanosome BES repertoires. CONCLUSION: With the exception of ESAG2, the BES sequence repertoires derived from T. b. gambiense are both less diverse than and nearly reciprocally monophyletic relative to those from T. b. brucei and T. equiperdum. Furthermore, although we find evidence for adaptive evolution in all three ESAG repertoires in T. b. brucei and T. equiperdum, only ESAG2 appears to be under diversifying selection in T. b. gambiense. This low level of variation in the T. b. gambiense BES sequence repertoires is consistent both with the relatively narrow host range of this subspecies and its apparent long-term clonality. However, our data does not show a clear correlation between size of trypanosome host range and either number of BESs or extent of ESAG genetic diversity.

Serious mental illness in Florida nursing homes: need for training.

This study examined how the mental health needs of nursing home (NH) residents with serious mental illness (SMI) are addressed. Data were collected from three sources: interviews with 84 SMI stakeholders; surveys of 206 NH staff members; and focus groups at two psychiatry specialty NHs. Four common themes emerged: placement of older adults with SMI was a significant problem for discharge planners and NH admission coordinators; NH staff reported being uneasy with SMI residents and were concerned over aggressive behavior; staff in NHs with psychiatry specialty units appeared more comfortable serving SMI residents; and SMI training was a consistent recommendation of all SMI stakeholders and NH staff. Implications for training are discussed.

Risk of Early Rehospitalization for Non-Behavioral Health Conditions Among Adult Medicaid Beneficiaries with Severe Mental Illness or Substance Use Disorders.

The goal was to examine risk factors and expenditures for early rehospitalization (within 30 days of discharge) for non-behavioral health conditions among Medicaid-enrolled Floridians over 8 years. There were 1,689,797 hospitalization episodes with 19% (N = 314,742) resulting in early rehospitalization. Total gross charges for early rehospitalization were over 13 billion dollars. In Cox proportional hazards regression adjusted for demographic and health covariates, drug use disorder was associated with 50% increased risk of early rehospitalization. Having major depressive disorder increased risk by 17%; psychotic disorder, bipolar disorder, and alcohol use disorder increased risk of early rehospitalization slightly by 10, 6, and 6% respectively. The effect of dementia on risk was minimal at 2%. Risk of early rehospitalization decreased by 3.5% per year over the 8 years of the study. Attention to mental health problems, especially drug use disorder, may help further reduce rates of early readmission for non-behavioral health conditions.

Snapshot of protein structure evolution reveals conservation of functional dimerization through intertwined folding.

Protein-protein interactions govern a wide range of cellular processes. Molecular recognition responsible for homodimerization and heterodimerization in the rel/NF-kappaB family of eukaryotic transcription factors relies on a small cluster of hydrophobic residues. We have carried out a structural analysis of six NF-kappaB p50 dimer interface mutants; one of them revealed a remarkable alteration. One or possibly both its mutations cause a switch into an intertwined dimer, in which the molecular partners exchange nearly half of their fold. In spite of the extensive swapping of secondary structure elements, the topology within each counterpart is preserved, with a very similar overall structure and minimal changes at the interface. Thus intertwining rescues structure and function from a destabilizing mutation. Since the mutants originate from a directed evolution experiment and are functional, the data provide an evolutionary snapshot of how a protein structure can respond to mutations while maintaining a functional molecular architecture.

Behavioral health service use and costs among children in foster care.

This article compares behavioral health service use and cost for foster care versus nonfoster care children; children before, during, and after foster care placement; and successfully reunified versus nonsuccessfully reunified foster care children. Behavioral health service costs for children in foster care were higher than for children not in foster care. Children in foster care used more services during their foster care placement than before placement and after discharge. Nonsuccessfully reunified children received a significantly larger quantity of services than those successfully reunified.

The role of coercion in the treatment of women with co-occurring disorders and histories of abuse.

Debate continues on issues of involuntary treatment for individuals with behavioral healthcare problems. Women with co-occurring disorders and histories of abuse are an especially vulnerable population. This study seeks to increase our knowledge about the experiences of coercion for women in the behavioral healthcare system. Patterns of coercion are explored. This study did not find the predicted relationship between high levels of interpersonal violence and frequent involuntary treatment experiences. The results do offer support for the hypothesis that women are more likely to be currently mandated to treatment if they have been recently arrested, and that being mandated to treatment does not appear to be related to clinical issues such as recidivism and acute symptoms. As expected, women currently required to be in treatment report having less choice in other aspects of their care. Implications for future research in the current climate of increasingly coercive policies are presented.

The relationship between mothers' child abuse potential and current mental health symptoms: implications for screening and referral.

This analysis examined data from mothers at 2 of the 9 sites participating in Substance Abuse and Mental Health Services Administration's (SAMHSA's) national Women Co-occurring Disorders and Violence Study (WCDVS). According to previous literature, it was hypothesized that women in the WCDVS would be at high risk of perpetrating child abuse. This research examined mothers' potential for physical child abuse and assessed the association between child abuse potential, current mental health symptoms, alcohol and drug use severity, and trauma. Results revealed that participants had significant potential for child abuse. Hierarchical regression analyses revealed that current mental health symptoms were the strongest predictor of mothers' scores on the Child Abuse Potential (CAP) Inventory. This study highlights the important relationships between commonly used instruments across the mental health, substance, and child welfare fields and the potential dual use of these instruments. Implications for policy and practice are discussed.

Physical health burdens of women with trauma histories and co-occurring substance abuse and mental disorders.

This article documents the physical health burdens of participants in a large, federally funded cross-site study of specialized services for women with histories of trauma (physical or sexual abuse) and co-occurring substance abuse and mental health disorders. Nearly half of the 2729 women in the study (48%) reported serious physical illnesses that frequently limited their daily life activities or required them to use special equipment. Nearly half (46%) rated their health status as only fair or poor. Given the prevalence of physical illnesses in this population, behavioral service providers should discuss with clients their overall health and how it might hinder their participation in treatment for trauma, substance abuse, and mental illness, and policymakers should consider this need when designing behavioral health requirements, setting reimbursement rates, and allocating funds.

Mental health service use and cost of care for older adults in assisted living facilities: implications for public policy.

With changing demographics prompting greater demand for assisted living facility (ALF) care, indigent older adults with mental health needs face underfunded residential care options and mental health systems currently unprepared to meet their service requirements. In particular, over-reliance on inpatient mental health services for older individuals with mental illness and inadequate reimbursement of ALF facilities potentially increase costs and threaten availability of ALF care. This article analyzes Florida's administrative data and presents findings on mental health service use and cost of care for poor older persons. Using Florida as an example, the authors recommend policy changes to ensure the quality and availability of residential care for low-income adults with mental health needs.

Students with mental illnesses in a university setting: faculty and student altitudes, beliefs, knowledge, and experiences.

Over the last decade, the topic of post-secondary supported education for people with severe and persistent mental illnesses has gained increasing attention and sparked interest in what colleges and universities can do to assist individuals with mental illnesses to achieve their educational goals. The purpose of this article is to discuss the issue and describe one university's strategy for improving the educational environment of students with psychiatric disabilities. We present findings from a survey designed to assess faculty and student attitudes, beliefs, knowledge, and experiences with students identified as having a mental illness.

Risk factors for early readmission to acute care for persons with schizophrenia taking antipsychotic medications.

OBJECTIVE The study examined risk factors for readmission to acute care among Florida Medicaid enrollees with schizophrenia treated with antipsychotics. METHODS Medicaid and service use data for 2004 to 2008 were used to identify adults with schizophrenia discharged from hospitals and crisis units who were taking antipsychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care. Cox proportional hazards regression estimated readmission risk in the 30 days after discharge and in the period after 30 days for participants not readmitted in the first 30 days. RESULTS The mean±SD age of the 3,563 participants was 43.4±11.1; 61% were male, and 38% were white. Participants had 6,633 inpatient episodes; duration of hospitalization was 10.6±7.0 days. Readmission occurred for 84% of episodes, 23% within 30 days. Variables associated with an increased readmission risk in the first 30 days were shorter hospitalization (hazard ratio [HR]=1.18, 95% confidence interval [CI]=1.10-1.27, p<.001), shorter time on medication before discharge (HR=1.19, CI=1.06-1.35, p=.003), greater prehospitalization use of acute care (HR=2.64, CI=2.29-3.05, p<.001), serious general medical comorbidity (HR=1.21, CI=1.06-1.38, p=.005), and prior substance abuse treatment (HR=1.58, CI=1.37-1.83, p<.001). After 30 days, hospitalization duration and time on medication were not significant risk factors. CONCLUSIONS Short hospital stays for persons with schizophrenia may be associated with risk of early readmission, possibly because the person is insufficiently stabilized. More chronic risk factors include prior acute care, general medical comorbidity, and substance abuse.

Predictors of avoidable hospitalizations among assisted living residents.

OBJECTIVES: Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care-sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003-2008. DESIGN: This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data. PARTICIPANTS: The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older. RESULTS: In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization. CONCLUSION: The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

The role of race and ethnicity in predicting length of hospice care among older adults.

BACKGROUND: The purpose of the study was to examine both direct and interactive roles of race/ethnicity with patients' characteristics (age, gender, relationship with caregiver, diagnosis, referral source, and payment type) in predicting length of hospice care. METHOD: This study included a total of 16,323 patients 65 years of age and older (M(age)=81.4, SD=8.3) who were served by a hospice in central Florida during a four-year period, 2002-2006. Survival analyses were conducted using the Cox proportional hazards model to predict the length of hospice care and test the interaction effects of race/ethnicity. RESULTS: The majority of subjects (83.5%) were white, 7.6% were African-American, and 8.9% were Hispanic. During the study period, 58.5% died. All patient characteristics were significantly associated with the length of hospice care (p < .05). Overall, Hispanics had the longest hospice stay (M=98.84 days), followed by African-Americans (M=90.29) and whites (M=88.20). With the exception of African-American women who were no more likely to stay longer under hospice care than African-American men, the women in this study stayed longer under hospice care than men did. Patients referred from long-term care (LTC) settings had shorter stays in hospice care compared to those referred by physicians in other settings. Additionally, African-Americans and Hispanics referred from LTC had significantly shorter hospice stays than those referred by primary physicians. CONCLUSION: In this limited sample of hospice patients, length of stay was longer for minority patients than white patients.